Authorization For Release Of Confidential Information Form - Arkansas Department Of Education
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1ONLY FOR ARKANSAS DEPARTMENT OF EDUCATION USE
AUTHORIZATION FOR RELEASE OF CONFIDENTIAL INFORMATION
By the Arkansas Child Maltreatment Central Registry
Applicant Instructions: Complete this form, have it notarized, and submit a preprinted check or a U.S. money order for $10.00 made
payable to the Arkansas Department of Human Services. DO NOT SEND CASH OR A TEMPORARY CHECK-YOUR REQUEST
WILL NOT BE PROCESSED. Make and keep a copy of this form for your records.
INCOMPLETE OR UNNOTARIZED FORMS WILL NOT BE PROCESSED BY THE CENTRAL REGISTRY OR THE ADE!
Mail this form to and the fee payment to:
Arkansas Child Maltreatment Central Registry
Applicant- Check Only One:
P.O. Box 1437, Slot S 566
Licensed Teacher
Little Rock, Arkansas 72203
Non-licensed/Classified
Applicant’s full name (print or type):
______________________________________________________________________
First
Middle
Last
List ALL other names used:
______________________________________________________________________
Applicant’s Social Security Number:
________- _________- ________
Applicant’s Birth Date (Month/Day/Year): __________________ Age: _____ Race/ethnicity: _______________ Gender: ____
Applicant’s mailing address: _________________________________
Physical Address: ____________________________
Street or P.O. Box
Street
_________________________________
____________________________
City
State
Zip Code
City
State
Zip Code
Applicant’s phone number : _____________________ (home) _______________________(cell)________________________(other)
List the full name and date of birth (Month/Day/Year) for all of the applicant’s children, attach additional paper if necessary:
1.
Child’s Full Name:
Child’s Date of Birth:
2.
Child’s Full Name:
Child’s Date of Birth:
3.
Child’s Full Name:
Child’s Date of Birth:
I hereby request that the Arkansas Child Maltreatment Central Registry release any information their files may contain indicating the
undersigned applicant as an offender of a true report of child maltreatment to the ARKANSAS DEPARTMENT OF EDUCATION.
By signing below, I swear or affirm that the foregoing statements are true to the best of my knowledge and belief under
penalty of perjury.
Applicant’s Signature: _________________________________________________
Date _________________
State of Arkansas County of _________________
On this the _____ day of __________, 20___, before me, ___________________(name of notary), the undersigned notary, personally
appeared _________________________(applicant’s name) known to me (or satisfactorily proven) to be the person whose name(s)
is/are subscribed to the within instrument and acknowledged that he/she/they executed the same for the purposes therein contained.
In witness whereof I hereunto set my hand and official seal.
Notary Public:___________________________________
My Commission Expires: _____________________
(APPLICANTS DO NOT WRITE BELOW THIS LINE)
_____________________________________________________________________________________________
School/District Contact Person
District Phone Number
District Fax
_____________________________________________________________________________________________
School Mailing Address
School District
LEA Number
ADE Form Effective Date (01/15/13)
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