Facility Requested Background Investigation Form
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1STATE OF COLORADO
John W. Hickenlooper
DIVISION OF BOARDS AND COMMISSIONS
Governor
Mary V. McGhee, Director
th
1575 Sherman Street, 7
Floor
Reggie Bicha
Denver, Colorado 80203-1714
Executive Director
Phone 303-866-4614
NOTICE: Price decrease to $25 effective November 1, 2013
FACILITY REQUESTED BACKGROUND INVESTIGATION
(Please print legibly)
Send this request with a check or money order for
$25
payable to CDHS, BIU, Records & Reports. Completed form
th
should be returned to: 1575 Sherman Street, 7
Floor, Denver, CO 80203. Incomplete or unsigned application
cannot be processed and will be returned. Do not send finger print cards. Cash payments will not be accepted.
Please circle one showing the nature of your business: Family Child Care Home, Child Care Center, Preschool,
School-Age Child Care Center, Day Treatment, Specialized Group Home, RCCF, Adoption (one form per couple),
Foster Care (one form per couple), Camp.
(Business officer completes the following facility information:)
Facility Name:_________________________________________ CDHS License No:____________________
Complete Address:__________________________________________________________________________
Business officer name and title: _______________________________________Phone:__________________
Full name of person to be checked:______________________________________________________
Maiden Name and other names used: ____________________________________________________
Birth Date:____________ Social Security No:_____________________ Sex: _____ Race:_________
Current Address:_____________________________________________________________________
Previous Address:____________________________________________________________________
Please circle one, and list your Spouse or Former Spouse or Parent(s) of your Children
(Add additional
names on back of this form):
Full Name:__________________________________________________________________________
Maiden Name and other names used: _____________________________________________________
Birth Date:____________ Social Security No:_____________________ Sex: _____ Race:__________
Please list your children and include dates of birth and sex
(Add additional children on back of this form)
_____________________________________________________________________________________
___________________________________________________________________________________
Signature of Person being checked:____________________________________ Date:____________
If you are under age 18, your parent or legal guardian must sign.
Note: Colorado criminal law governs misuse of information in the state database on child abuse or
neglect, including false statements. CDHS promptly investigates violations and takes necessary
action.
Our Mission is to Design and Deliver Quality Human Services that Improve the Safety and Independence of the People of Colorado
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