Child Care Licensing Request For Background Check
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1Texas Dept of Family
Form 2971
and Protective Services
Aug 2011
CHILD CARE LICENSING
Page 2 of __
REQUEST FOR BACKGROUND CHECK
“Texas law gives you the right to know what information is collected about you by means of a form you submit to a state government agency. You
can receive and review this information, and request that incorrect information about you be corrected by contacting your licensing representative.”
Initial
24 Month Check
Fingerprint Check Required
FBI Results in DPS Clearinghouse
Social Security Number
ID Type - Drivers License or ID Number -State
First Name
Middle Name
Last Name
Street Address
City
State
Zip
County
Telephone No. (A/C)
Date of Birth
Gender
M
F
You must list any other city in Texas where this person has been a resident, and any addresses, including county, where the person has lived outside
of Texas in the previous five years:
Relationship of person to requestor
Adoptive Parent
Caregiver
Director
Foster parent
Household Member
Licensed Administrator
Other Staff
Staff
Volunteer
Other:
For Foster/Adoptive Homes only: Relationship between child/children to be placed and the foster/adoptive parent(s) or prospective foster/adoptive
parent(s)
Relative
Fictive Kin
Unrelated
Date Hired /Used by the
Ethnicity (must accompany race)
Race
Operation/Agency
White
Asian
Hispanic
Other
Black
American Indian/Alaskan Native
Unable to Determine
Native Hawaiian/ Pacific Islander
Other names used (married, maiden, etc.) First Name
Middle Name
Last Name
Initial
24 Month Check
Fingerprint Check Required
FBI Results in DPS Clearinghouse
Social Security Number
ID Type - Drivers License or ID Number -State
First Name
Middle Name
Last Name
Street Address
City
State
Zip
County
Telephone No. (A/C)
Date of Birth
Gender
M
F
You must list any other city in Texas where this person has been a resident, and any addresses, including county, where the person has lived outside
of Texas in the previous five years:
Relationship of person to requestor
Adoptive Parent
Caregiver
Director
Foster parent
Household Member
Licensed Administrator
Other Staff
Staff
Volunteer
Other:
For Foster/Adoptive Homes only: Relationship between child/children to be placed and the foster/adoptive parent(s) or prospective foster/adoptive
parent(s)
Relative
Fictive Kin
Unrelated
Date Hired /Used by the
Ethnicity (must accompany race)
Race
Operation/Agency
White
Asian
Hispanic
Other
Black
American Indian/Alaskan Native
Unable to Determine
Native Hawaiian/ Pacific Islander
Other names used (married, maiden, etc.) First Name
Middle Name
Last Name
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