Background Screening Application - Ywca Utah printable pdf download

DHS OL

CBS USE ONLY

February 2015

UTAH DEPARTMENT OF HUMAN SERVICES OFFICE OF LICENSING

195 North 1950 West, Salt Lake City, Utah 84116

BACKGROUND SCREENING APPLICATION

For Programs Licensed to Provide Services to Children or Vulnerable Adults

Foster, Proctor, Professional Parents & Adoptive Parent for a Child in State Custody

and DSPD Certified Providers

APPLICANT INFORMATION, AUTHORIZATION AND RELEASE

Instructions: This section to be completed by the Applicant. Read each box and answer the following questions. Use the back of this page or attach another

page if you need more space. Incomplete (missing information) and/or illegible (unreadable) applications will be returned.

First (given) Name:

Middle Name as it appears on your birth certificate:

Last Name:

(No Maiden Name. Indicate if middle name is an

initial only. Use N/A if no middle name.)

ALL Alias, Maiden & Previous Married Names:

Date of Birth ______ / _______ / _________

Social Security No. _____ - ______ - _________

Phone Number: (

)

Mailing Address:

City:

State:

Zip Code:

2. Have you ever been charged with a crime by any law enforcement authority? A crime is any unlawful activity; an act committed in violation of a law

forbidding it; an act that is punishable upon conviction; any infraction, misdemeanor or felony. Disclose ALL CRIMINAL OFFENSES even if they

were later dismissed or you completed a plea in abeyance or diversion program whether you pled guilty or not guilty to an offense, or if you are waiting to

enter a plea to the court.

Yes

If yes to 2, please attach a certified court docket or other certified record (available from the court that handled your case) indicating the

disposition of each charge or offense, or the status of each plea in abeyance or diversion agreement. If you previously submitted the

certified court record to the Office of Licensing for background screening, please use the space below to write the charge, court, and date.

3. Have you ever been investigated for child or adult abuse or neglect by Child Protective or Adult Protective Services?

Yes

If yes to 3, please attach complete certified case report showing final outcome. If previously submitted, provide a detailed explanation of

the investigation including the names, dates, location and the case number if known.

4. In the last five (5) years, have you lived in or have you spent six (6) or more consecutive weeks in a foreign country or U.S. Territory?

Yes

If yes to 4, list each country separately and attach an original criminal history report from each country or an original letter of honorable

release from the U.S. military or full-time ecclesiastical service from each country lived in.

COUNTRY

FROM month/year

TO month/year

5. In the last five (5) years, have you lived in or have you spent six (6) or more consecutive weeks in a U.S. state besides Utah?

Yes

If yes, list each state separately.

STATE

COUNTY

FROM month/year

TO month/year

If yes to 5, or you hold an out of state driver license or out of state I.D. Card, you must complete a nation-wide fingerprint based background check. Submit

two professionally rolled, complete fingerprint cards with this application and a money order, cashier’s check or company check for $34.75 for each applicant

payable to the Department of Human Services.

6. I authorize the Utah Department of Human Services Office of Licensing to investigate my past and present child and adult abuse, neglect and exploitation

records, law enforcement, driver license, and any all information which may be pertinent to my application according to Utah Code 62A-2-120, 121, 122, and

Rule 501-14. I authorize the release of any and all information. I release the Department of Human Services from any damages resulting from the

Department of Human Services furnishing such information to authorized agencies. I certify my answers contain no misrepresentations or falsifications, and

the information is true and complete to the best of my knowledge. I have reviewed and verified the accuracy of this background screening application.

I understand that providing false or inaccurate information or failing to provide information may result in my background screening being denied.

Applicant Signature

Date

Program Name

: _________________________________________________________________________________________________

DO NOT WRITE OR MARK IN THE SPACE BELOW. THIS SPACE IS FOR CBS USE ONLY. STAMPS BELOW DESIGNATE APPROVAL.

PL 109-248

PL 109-248 CAN

62A-2-120

LIS-C

MIS-A