Authorization For Background Study - Steele County Human Services

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STEELE COUNTY
630 Florence Avenue
P.O. Box 890
HUMAN SERVICES
Owatonna, MN 55060
Charity Floen
Tel. 507-444-7500
FAX 507-451-5947
Director
AUTHORIZATION FOR BACKGROUND STUDY
DATE:_____________________
LICENSE HOLDER NAME:_________________________ADDRESS:_______________________________________
STREET / CITY / STATE / ZIP
CHECK ONE:
CHILD FOSTER CARE
ADULT FOSTER CARE
FAMILY CHILD CARE
DUAL LICENSING________________________________________
RESPITE CARE
OTHER__________________________________________________
The individual below is:
Applicant for licensure
Family Member over age 13 years
Substitute Caregiver
Existing Employee (Relicensing)
New Employee
Other__________________________
(FULL LEGAL NAME – DO NOT USE INITIALS OR NICK NAMES)
/ ______________________________________
NAME:_________________________________________________________
(Last)
(First)
(Middle)
Previous/Maiden/Married Name
DATE OF BIRTH:_______________ MALE
FEMALE
DRIVERS LICENSE#____________________________
M / D / YR
ADDRESS:_________________________________________________________________________________________________
STREET
CITY
STATE
ZIP
COUNTY
SOCIAL SECURITY #____________________HOME PHONE___________________WORK PHONE____________________
HAVE YOU RESIDED AT THE ABOVE ADDRESS FOR OVER 5 YEARS? YES
NO
IF NO PLEASE LIST ALL
CITIES, STATES AND COUNTIES WHERE YOU MAINTAINED RESIDENCE DURING THE LAST FIVE YEARS.
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
I HEREBY AUTHORIZE THE AGENCY BELOW TO RELEASE THE REQUESTED INFORMATION TO STEELE COUNTY
HUMAN SERVICES. I UNDERSTAND THE INFORMATION MAY BE RELEASED TO MINNESOTA DEPARTMENT OF
HUMAN SERVICES. I HEREBY AUTHORIZE THE MINNESOTA BUREAU OF CRIMINAL APPREHENSION TO RELEASE
MY CRIMINAL HISTORY TO STEELE COUNTY HUMAN SERVICES PURSUANT TO MINNESOTA STATUTE 245A.04.
SUBJECT SIGNATURE_____________________________________________
FOR CHECKING AGENCY USE ONLY
SEARCHING COUNTY:____________________________
BCA/
SOCIAL SERVICES / ADULT / CHILD CASE RECORDS
LAW ENFORCEMENT
INITIALS:___________________DATE:____________
JUVENILE COURT RECORDS
INITIALS:_________________DATE:_______________
INITIALS:___________________DATE:_____________
“AN EQUAL OPPORTUNITY EMPLOYER”

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