Form Cfs 718-A - Authorization For Background Check For Foster Care And Adoption - The Illinois Dcfs
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1
2CFS 718-A
Illinois Department of Children and Family Services
Rev 12/2014
AUTHORIZATION FOR BACKGROUND CHECK for Foster Care & Adoption
READ INSTRUCTIONS ON REVERSE SIDE AND PRINT ALL INFORMATION
CHECK ONE BOX IN EACH COLUMN IN THE APPLICABLE ROW A or B:
Category of Facility
Specific Type of Application
Person in the Home
Initial
Applicant
Renewal
Member of Household (ages 13 to 17)*
Foster Care
1
Relative
*Parent/Guardian signature required
A
Traditional
Member of Household (age 18 and over)
ICPC
Ward
Adopt Only Home
For Placement Purposes
Adoption
Unlicensed Relative in Illinois
For Adoption Purposes
B
Unlicensed Relative Out of State
PERSONAL INFORMATION (Please see additions instructions on the back page)
Last Name/First Name/Middle Initial
__ __ __ - __ __ - __ __ __ __
Social Security or ITIN Number
I am or will be transporting foster children
Yes
No
Maiden and/or Any Names Formerly Used (Last/First/Middle Initial)
If this statement is yes, list your Drivers License number here:
__ __ __ __ - __ __ __ __ - __ __ __ __
Is this an Illinois Drivers License Number?
Yes
No
CURRENT ADDRESS, TELEPHONE (when applicable):
List all previous addresses for the past five (5) years,
including those outside of Illinois.
Dates
Street/Apt.#:
(Street/Apt.#/City/County/State/Zip Code)
From/To
__ __
:
City:
State
2
__ __ __ __ __
Zip Code:
County:
( __ __ __ ) __ __ __ - __ __ __ __
Home Telephone
( __ __ __ ) __ __ __ - __ __ __ __
Cell Phone
Have you lived outside of Illinois in the past 3 years?
Yes
No
Date of Birth
Age
Place of Birth
Citizenship
Gender
Height
Weight
Hair
Eye
(Country)
(Month/Date/Year)
(City and State)
Ft.
In.
(lbs.)
(color)
(color)
USA
M
Other Specify
-
-
F
Ethnicity
Race (Check all that apply)
(see codes on Page 2)
Native American/Alaskan (Indian or Eskimo)
Black/African American
White
Declined to Identify
Asian
Native Hawaiian/Pacific Islander
Unknown
Could not be Verified
AUTHORIZATION /CERTIFICATION
Have you ever been indicated as perpetrator in a child abuse/neglect investigation?
Yes
No
Have you ever been convicted of a criminal offense, other than a minor traffic violation?
Yes
No
I certify that I have read and understood the Authorization/Certification box on the back page of this form.
3
SIGNATURE
DATE
Parent/Guardian Signature (if applicable)
DATE
TO BE COMPLETED BY SUPERVISING AGENCY
This authorization form will not be processed without completion of this section. The licensing representative must complete the following
Date Fingerprinted:
Supervising Agency Name:
Full Name of Facility
Provider ID#
Or
4
Provider ID #
DCFS Region/Site/Field
Street Address:
Name of Worker
Worker ID#/Phone Number
City
IL
ZIP:
Name of Supervisor
Supervisor ID#/Phone Number
BACKGROUND RESULTS AS APPLICABLE
FOR CENTRAL OFFICE OF LICENSING USE
Sex Offender Clearance:
SID#
Clear
Record
CANTS Clearance:
BC-03 Registered:
5
Illinois State Police Clearance:
FBI Sent Out:
FBI Clearance:
Valid Driver's License: Yes __________ No ___________
Transfer Clearances: SO/CANTS:
ISP:
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