Form Dphhs-Qad/ccl-20a - Release Of Information For Registered And Licensed Child Care Providers Criminal

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DPHHS-QAD/CCL-20A
OFFICE USE
(Revision 11-10)
CAPS# _____________
DEPARTMENT OF
PS# ________________
PUBLIC HEALTH AND HUMAN SERVICES
STATE OF MONTANA
- RELEASE OF INFORMATION -
For Registered and Licensed Child Care Providers
Criminal / Protective Service / Motor Vehicle
Background Checks
PERSONAL INFORMATION
Section A – Current Information
Phone # ________________________
Legal Name: ______________________________________________________________________________________
(First)
(Middle)
(Maiden)
(Last)
Aliases/Other Names Used: __________________________________________________________________________
Residential Address: ________________________________________________________________________________
(Street)
(City)
(State)
(Zip)
Mailing Address: ___________________________________________________________________________________
(Street)
(City)
(State )
(Zip)
Sex: [
] Male
[
] Female
Date of Birth: _________________ Social Security #_________________________
Section B – Past Residences
Within the last five (5) years, have you…
…lived in another state?
1.
[
] Yes
[
] No
…lived on or do you now live in an area designated as an Indian reservation?
2.
[
] Yes
[
] No
If you answered yes to the any of the above questions:
 Please state where you have lived since turning 18 in the table below.
 You will need to obtain an out of state background check or a tribal background check at your cost.
Dates of Residency (From – To)
City
County
Reservation
State
Section C – Prior Caregiver Approvals
Have you been…
…registered / licensed to care for children before?
[
] Yes
[
] No
…approved, in any capacity, to provide care in a child care facility?
[
] Yes
[
] No
IF YES: Please give the Director / Facility Name and the Dates at the facility.
_________________________________________________________________________________________________
(Director / Facility Name)
(Dates)
_________________________________________________________________________________________________
(Director / Facility Name)
(Dates)
PLEASE COMPLETE BOTH SIDES OF THIS FORM

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