Form Cfs-342 - State Police Criminal & Fbi Record Check Release

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Arkansas Department of Human Services

Division of Children and Family Services

STATE POLICE CRIMINAL & FBI RECORD CHECK RELEASE

THIS SECTION TO BE COMPLETED BY DCFS WORKER. CHECK ALL THAT APPLY.

Foster Parent

Adoptive Parent

FFSS (

______________________________

for which Foster Family):

Provisional

ICPC Reg No. 7

Court Ordered

Other ____________________________

ONLY Provisional, ICPC Reg No. 7, and Court Ordered Checks will be expedited.

State Only

State/FBI (fingerprint card included)

State/FBI (fingerprints to be run via harvester)

County Requesting Check and County Number

Name of DCFS Worker Requesting the Check

(

)

Telephone Number and Extension Number

Date of Request

THIS SECTION TO BE COMPLETED BY THE PERSON TO BE CHECKED (PLEASE PRINT)

LEGAL NAME:

Last (Include Jr., II, III)

First

Middle

MAIDEN NAME:

EMAIL ADDRESS:

CURRENT STREET ADDRESS:

CITY/STATE/ZIP:

DATE OF BIRTH:

AGE:

RACE:

SEX: Male

Female

STATE OF BIRTH:

CITIZENSHIP:

SOC SEC #:

HEIGHT:

WEIGHT:

EYE COLOR:

HAIR COLOR:

DRIVER’S LICENSE OR STATE ID NUMBER:

ISSUED BY STATE OF:

HAVE YOU EVER BEEN CONVICTED OF A CRIME? NO

YES

(If yes, please provide a description of the crime and the

particulars of the conviction.)

THE FOLLOWING IS TO BE COMPLETED ONLY IN THE PRESENCE OF A NOTARY

I hereby authorize the Department of Human Services to obtain a Criminal Record and FBI Checks through the Arkansas State Police in accordance with Act

1573 of 2005. I provide this consent now for current and future checks as requested by the Department of Human Services. I understand that at any time I may

revoke this continuing permission in writing. I state on oath that the representations made herein are true and correct. I understand that I may challenge the

accuracy and completeness of any information in any report and obtain a prompt determination as to the validity of the challenge before a final determination is

made by the board. I understand that I may be denied a license or exemption to operate a child welfare agency or may be denied unsupervised access to

children in the care of a child welfare agency due to information obtained by this check that indicates I have been convicted of, or am under pending indictment

for a crime per ACA § 9-28-409. I understand that any background check and the results thereof shall be handled in accordance with the requirements of Pub. L.

No. 92-544.

Signature of Applicant

Date

State of Arkansas, County of ________________________. Subscribed and sworn to before me a Notary Public in

and for the county and state aforesaid, this _______ day of ____________________, _____.

Notary Public

My Commission Expires on __________________________, _______.

CFS-342 (02/2016)

Initials_________ Date Completed ___________ Harvester Transaction Number

_____________

(if applicable)