BACKGROUND AUTHORIZATION
Read all instructions before completing this form
Form must be dated and signed
SECTION 1. Completed by the Department of
SECTION 2. Required Information Completed by Provider and Initialed by Applicant
Early Learning
Name and address of child care provider
Applicant’s Initials:_____
DEL Local Office and Office ID
Provider # (Required)
(Leave blank if not currently licensed)
Provider’s E-mail address
Mailing address if different
DEL Inquiry ID #
Applicant check the appropriate box as it applies.
Employee or Household member
Volunteer
Additional facilities with the same owner that the applicant may also be cleared for - (multiple site facilities only)
Provider #
Provider #
Provider #
Provider #
Applicant’s Initials:_____
Applicant’s Initials:_____
Applicant’s Initials:_____
Applicant’s Initials:_____
SECTION 3. Applicant Information --(Completed by person to be checked
4. Current phone number (Required)
2.Social Security Number
3. Date of Birth (MM/DD/YYYY)
(Optional)
(Required)
(Write NONE if none)
(
)
-
5.Print your complete name(s) (Required)
5a. Current last name
5b. Current first name
5c. Current middle name
(Write NONE if none)
(Write NONE if none)
(Write NONE if none)
6a. Birth last name (write SAME if same as
6b. Birth first name (write SAME if same as
6c. Birth middle name (write SAME if same as
current name)
current name)
current name)
7. Other names you have used or been known by. List all combinations of names; Include your name exactly as listed on your State
license or ID card (Required)
(Write NONE if none)
Last name(s)
First name or nickname
Middle name(s) or second name(s)
8.a. Name of state where the current driver’s license or state identification was issued:
9. How many years have you lived in WA state
without living anywhere else? (Required)
8b. Current driver’s license or state identification number (Write NONE if none)
Years
Months
(For Washington State this must be 12 digits)
If you have lived in WA State for less than three years you must complete the fingerprint process – see instructions for details
10a. Current address: Where you live now (REQUIRED)
Street
City
State
Zip Code
From Month
Year
To
Month
Year
10b. Previous address – The address where you lived if your current address is less than 3 years.
Write NONE if you do not have a previous address.
STREET
City
State
Zip Code
From
Month
Year
To
Month
Year
10.9.2.1 Background Check Form
Rev. 8/11
1