Form Dshs 09-653 - Background Authorization printable pdf download

Background Authorization

Read the attached instructions before completing this form.

SECTION 1. ENTITY INFORMATION (COMPLETED BY DSHS STAFF, PROVIDER, APPLICANT, LICENSEE, AND/OR CONTRACTOR)

1A. GIVE NAME OF PERSON OR ENTITY

1B. SEE INSTRUCTIONS: GIVE ENTIRE ADDRESS OF PERSON OR

1C. REQUIRED BY CHILDREN’S ADMINISTRATION ONLY:

REQUESTING THIS BACKGROUND CHECK

ENTITY REQUESTING THE CHECK

GIVE NAME OF FACILITY/FOSTER HOME

Citizen Access Residential

617 Cherry St SE

Olympia, WA. 98501

NAME AND SIGNATURE OF PERSON REQUESTING THE BACKGROUND CHECK

Thomas E Frey

PRINTED NAME:

SIGNATURE:

3. A. REQUIRED ONLY FOR ECONOMIC SERVICES ADMINISTRATION:

WorkFirst contract

Protective Payee

In-home relative

In loco parentis

B. REQUIRED ONLY FOR CHILDREN’S ADMINISTRATION:

State foster care

Private agency foster care

Adoption

DCFS relative placement

Contracts

Subject of (or related to) CPS investigation

Residential facility or child placing agency employee

C. REQUIRED ONLY FOR ADULT PROTECTIVE SERVICES:

Subject involved in (or related to) APS investigation per RCW 74.34

D. REQUIRED ONLY FOR DSHS STATE EMPLOYMENT:

DSHS POSITION NUMBER

(WRITE NONE IF NONE)

DSHS JOB CLASSIFICATION:

PERSONNEL IDENTIFICATION NUMBER:

Permanent appointment

Non-permanent appointment

Work study

Volunteer

Student internship

Layoff

On-Call

4. SEE INSTRUCTIONS: BCCU ACCOUNT NUMBER

5A. SEE INSTRUCTIONS: DSHS ID NUMBER OR

5B. FOR WEB SERVICE FINGERPRINT CHECK: BCCU INQUIRY ID NUMBER

NAME

11001268

SECTION 2. THIS SECTION IS FOR APPLICANT INFORMATION ONLY (THE PERSON TO BE CHECKED IS THE APPLICANT)

6. SEE INSTRUCTIONS: SOCIAL SECURITY NUMBER

PRINT YOUR DATE OF BIRTH (MM/DD/YYYY)

8A. SEE EXAMPLE IN INSTRUCTIONS: PRINT YOUR LAST

SEE EXAMPLE IN INSTRUCTIONS: PRINT YOUR FIRST

SEE EXAMPLE IN INSTRUCTIONS: PRINT YOUR MIDDLE

NAME AS IT IS NOW (WRITE NONE IF NONE)

8B. PRINT YOUR LAST NAME AT BIRTH

PRINT YOUR FIRST NAME AT BIRTH

PRINT YOUR MIDDLE NAME AT BIRTH

(WRITE NONE IF NONE)

9. PRINT OTHER LAST NAMES YOU HAVE USED AND LAST NAMES YOU HAVE BEEN KNOWN BY (WRITE NONE IF NONE)

10. PRINT YOUR NICKNAMES AND ALL OTHER FIRST NAMES YOU HAVE USED AND HAVE BEEN KNOWN BY (WRITE NONE IF NONE)

11A. Have you been convicted of any crime? If yes, fill in the blanks below. Add a page if you need more room...................................

Yes

Felony and gross misdemeanor crimes:

Degree:

State:

Conviction date:

11B. Do you have charges (pending) against you for any crime?

If yes, fill in the blanks below. Add a page if you need more room. ....................................................................................................

Yes

Felony and gross misdemeanor crimes:

Degree:

State:

12.

Have you ever received a notice from a court or state agency stating that you have sexually abused, physically abused,

neglected, abandoned, or exploited a child, juvenile, or adult? .............................................................................................................

Yes

13.

Has a court or state agency ever denied you a contract or license; terminated, revoked or suspended your contract

or license; or have you ever given up your contract or license because a court or agency was taking action against you?.................

Yes

14.

Has a court ever written an order of protection or a restraining order lasting more than 30 days against you for

abuse, neglect, financial exploitation, domestic violence, or abandonment of a vulnerable adult, juvenile, or child? .........................

Yes

15. PRINT YOUR DRIVER’S LICENSE OR STATE IDENTIFICATION NUMBER (WRITE NONE IF NONE)

PRINT THE NAME OF THE STATE ON YOUR LICENSE OR ID

16. How many years have you lived in Washington State without living in another state?

Years

Months

17.

A. PRINT THE STREET ADDRESS WHERE YOU LIVE NOW

CITY

STATE

ZIP CODE

COUNTY

B. SEE INSTRUCTIONS: PRINT THE STREET ADDRESS WHERE YOU LIVED BEFORE YOUR CURRENT ADDRESS

CITY

STATE

ZIP CODE

COUNTY

C. SEE INSTRUCTIONS: GIVE THE DAYTIME AREA CODE AND TELEPHONE NUMBER WHERE YOU CAN BE REACHED

18. I am the person named above. If I do not tell the whole truth on this form, I understand I can be charged with perjury and I may not be allowed to

work with vulnerable adults, juveniles or children. My signature in box number 19 means:

•

I give DSHS permission to check my background with any governmental entity and law enforcement agency.

•

If a founded finding is identified, I give DSHS permission to give only my name and that a founded finding was identified to any persons or entities

in Section 1.

•

I give DSHS permission to give all my other background information to the persons or entities named in Section 1.

•

This permission is good for 90 days from the date signed. I can change my mind about this permission in writing at any time.

19. REQUIRED: YOUR SIGNATURE. YOUR PARENT OR GUARDIAN’S SIGNATURE IF YOU ARE UNDER 18.

20. REQUIRED: TODAY’S DATE (MM/DD/YYYY)