Pennsylvania Child Abuse History Clearance Forms Page 2
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4PENNSYLVANIA CHILD ABUSE HISTORY CLEARANCE
CHILDLINE USE ONLY
COMPLETE SECTION I ONLY. PRINT CLEARLY IN INK. ENCLOSE $10.00 MONEY ORDER
DATE RECEIVED BY CHILDLINE
ONLY. PAYABLE TO DEPARTMENT OF PUBLIC WELFARE. DO NOT SEND CASH OR
PERSONAL CHECK.
SEND TO CHILDLINE AND ABUSE REGISTRY, DEPARTMENT OF PUBLIC WELFARE,
P . O . B O X 8 1 7 0 H A R R I S B U R G , P A 1 7 1 0 5 - 8 1 7 0
APPLICATIONS THAT ARE INCOMPLETE ILLEGIBLE OR RECEIVED WITHOUT FEE WILL
BE RETURNED UNPROCESSED. IF YOU HAVE QUESTIONS CALL 717-783-6211
SECTION I
APPLICANT IDENTIFICATION
IN THIS SPACE PRINT APPLICANTS FULL NAME AND ADDRESS (DO NOT USE INITIALS)
SOCIAL SECURITY NUMBER
NAME
STREET
DAYTIME PHONE NO.
AGE
DATE OF BIRTH
CITY, STATE
ZIP CODE
SEX
COUNTY YOU LIVE IN
F
M
PREVIOUS NAMES
USED SINCE 1975 (Include Maiden Name, Nicknames, Aliases)
(FIRST, MIDDLE, LAST)
(FIRST, MIDDLE, LAST)
PURPOSE OF CLEARANCE (Check ONE block ONLY)
CHI L D CA RE
VOLUNTEERS-A copy of your PROCESSED 'Request
CW EP (Community Work Experience Program
f o r C r im in a l R e c o r d " ( F o r m S P 4 - 1 6 4 ) m u s t b e
Participant)
FOSTER CARE
attached. Out-of-state residents must also attach a
c o p y of t h e ir PRO C ES SED F BI c le a r a n c e ( F or m
A D O P T I O N
FID-258).
SCHOOL
SIGNATURE OF CAO REP
CAO PHONE NO
PREVIOUS ADDRESSES SINCE 1975 (Attach additional pages if necessary)
1.
2.
3.
4.
HOUSEHOLD MEMBERS (List everyone who lived with you at anytime since 1975 to the present).
PRESENT
SEX
NAME (First, Middle, Last) Do not use initials.
RELATIONSHIP
AGE
1.
2.
3.
4.
5.
6.
I certify that the above information is accurate and complete to the best of my knowledge and belief and submitted as
true and correct under penalty of law (Section 4904 of the Pennsylvania Crimes Code).
Applicants are required to show the Administrator the original
document. Administrators are required to keep a copy of this
child abuse history record on file. Any person altering the
contents of this document may be subject to civil, criminal or
APPLICANT'S SIGNATURE
DATE
administrative action.
-
DO NOT WRITE IN THIS SECTION
CHILDLINE USE ONLY
SECTION II
RESULTS OF HISTORY CHECK
APPLICANT IS NOT LISTED IN A REPORT OF CHILD ABUSE
APPLICANT IS LISTED IN A REPORT OF CHILD ABUSE OR A
REPORT FOR SCHOOL EMPLOYEE (SEE BELOW).
OR A REPORT FOR SCHOOL EMPLOYEE.
STATUS OF REPORT
DATE OF INCIDENT
STATUS OF REPORT
DATE OF INCIDENT
1.
3.
2.
4.
VERIFIER
DATE
VERIFIER'S SUPERVISOR
DATE
03460C
12/99
CY 113
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