Background Screening Application - Ywca Utah Page 2
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2DHS OL
February 2015
BACKGROUND SCREENING APPLICATION – Page 2
To be completed by Program Representatives or Foster Care Licensor
Applicant First Name: _______________________ Last Name: ____________________________ Social Security Number: _______/_______/__________
APPLICANT
Circle Valid Identification Type
Issued by (State) See #5
ID Number
Expiration date
Identification
Information
Driver License
State ID
LICENSED PROGRAM CERTIFICATION AND RELEASE
Complete all fields. Incomplete/illegible applications will be returned.
Program Type - Circle all that apply for this applicant.
Adam Walsh Adoption Child Placing DSPD Certified Provider Employee Foster Care Residential Treatment Other:_________________________
- - -
Services for a child in state custody
7a. Is the applicant applying to provide foster, proctor or professional parent or adoptive services for a child in state custody?
Yes
No
7b. If the applicant is the spouse or another adult living in the home, the full name of the Main Provider is_________________________________________
7c. Is this a first-time application to provide services for a child in state custody with this facility / licensor?
Yes
No
If yes to 7c. State and federal legislation require compliance with fingerprint-based checks of national crime information databases, and/or state child abuse
registries for prospective foster, proctor, or adoptive parents of a child in state custody. Have the applicant make an appointment for a fingerprint live scan at
any one of the DCFS Region Live Scan locations (see list at: scan sites.pdf) and present this completed form along with a
money order or cash only for the exact amount of $10 scanning fee for each applicant.
- - -
Program Name
Mailing Address
City
State
Zip Code
Print Program Representative or DHS Licensor (foster care only) Name
Phone
8. I certify that I have inspected the applicant’s social security card and state driver license or state identification card issued by the Driver License Division,
they do not appear to have been forged or altered. I have reviewed the entire completed application, applicant and licensed program sections, and they
contain no misrepresentations or falsifications to the best of my knowledge. The licensed program releases the Department of Human Services from any
damages resulting from disclosing information to authorized agencies. The licensed program shall not disclose this form or its contents except as authorized
by Utah or federal law.
Signature (must be original)
Date
IMPORTANT INFORMATION AND INSTRUCTIONS
Updated information or forms may be found at our website:
Download the Background Screening Application from the website ONLY.
All information must be accurate, legible and complete. Please no two sided (back to back) applications.
Answering YES to questions #2, #3, #4 or #5 requires additional documentation. See each question for
clarification or requirements. Applications will be returned unprocessed if all required documentation is not
attached.
Please observe a two-week time period before requesting the status of submitted applications.
If an applicant is no longer associated with your facility, please fax us a notice on your company letterhead to the
Background Screening Unit fax: 801-538-4669.
Please contact your licensor for any changes to your mailing address or facility name.
Any questions? Call your licensor, your background screening technician or the Office of Licensing receptionist at 801-538-4242.
Thank you.
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