Background Authorization - Washington State Department Of Early Learning (Page 3 of 4) in pdf

INSTRUCTION SHEET FOR FILLING OUT THE BACKGROUND AUTHORIZATION FORM

You must fill in ALL boxes on this form as instructed. READ the instructions for each Section and each box.

Most background authorization forms are sent back for the following reasons:



The wrong form is used

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Some boxes are not filled in

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It is hard to read the handwriting

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A person under 18 signs the form without a parent or guardian signature

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The form is signed and dated more than three months from the date DEL received the form

Section 1: This section is completed by the Department of Early Learning

Section 2: This section must be completed by the licensee and initialed by the applicant. The licensee is the

program licensed by DEL. Fill in the licensee name and address as it is or will be listed on the license.

The Provider # is the number found at the top left hand side of the license. It is your license control ID. It is NOT the

SSPS Provider number. If you are applying to be licensed for the first time, go to Section 3.

Section 3: You MUST fill out this section if you are the person we are checking.

2. You MAY put your social security number (SSN) in this box. Your SSN is not required.

3. You MUST fill in your date of birth.

4. You MUST fill in your phone number. You MUST put NONE if you do not have a phone number.

5a. You MUST put your last name. If you do not have a last name, you MUST put NONE.

5b. You MUST put your first name. If you do not have a first name, you MUST put NONE.

5c. You MUST put your middle name. If you do not have a middle name, you MUST put NONE.

6a. You MUST put your Birth last name. You MUST put SAME if it is the same as your name in 5A.

6b. You MUST put your Birth first name. You MUST put SAME if it is the same as your name in 5B.

6c. You MUST put your Birth middle name. You MUST put SAME if it is the same as your name in 5C.

7. You MUST put any other names you have been known by including nicknames. This includes name as it appears on

your State identification. You MUST put NONE if you have NOT used or been known by any other name.

8a. You MUST put the name of the state in the box.

8b. Current driver’s license or state identification number.

9. You MUST put the number of years and months you have lived in Washington State without living in another state or

country. If you have moved out of Washington to another state or country, you MUST start counting the years and months

from the date you moved back to Washington State. This includes attending school in another state.

10a. You MUST fill in the address where you live now. You MUST indicate the years and month you have lived at this

address.

10b. You MUST fill in the address where you lived prior to your current address if you have lived at your current address

for less than three years. Write NONE if you do not have a previous address.

10.9.2.1 Background Check Form

Rev. 8/11

Background Authorization - Washington State Department Of Early Learning Page 3