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3SHP-159H
02/10
Missouri State Highway Patrol / Missouri Department of Social Services
REQUEST FOR CHILD ABUSE OR NEGLECT / CRIMINAL RECORD
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TYPE OF DAYCARE PROVIDER
TYPE OF SERVICE (Check ALL that apply) See reverse side for further instructions.
(1) CD Central Registry Child Abuse Search Only - No Charge
(1) License
(2) Name Search - $10.00 (Criminal record, child abuse, or neglect, central registry search)
(3) Fingerprint Search
(2) License Exempt
$14.00 (Authorized Statute 210.487)
(3) Registered
$20.00 (All other request)
IDENTIFYING DATA (Please type or print information legibly in ink.) The subject of the request must complete the next section and sign.
APPLICANTʼS NAME (Last, First, MI, Jr., Sr., III)
MAIDEN NAME
DATE OF BIRTH (MM/DD/YY) STATE OF BIRTH
SEX
RACE
ALIAS NAME(S)
SOCIAL SECURITY NUMBER
DRIVERʼS LICENSE NUMBER / STATE
DRIVERʼS LICENSE NUMBER
/
STATE
ADDRESSES FOR PAST 5 YEARS
STREET
CITY
STATE
STREET
CITY
STATE
Have you ever been found guilty to or been convicted of any criminal act in this state or any state?
YES (Complete section below)
NO, I have not been found guilty to or been convicted of any criminal offense in this state or any state.
DATE
CITY
STATE
COUNTY
CIRCUMSTANCES (Identify charges, attach separate page, if necessary.)
Have you ever been substantiated as a perpetrator in any child abuse or neglect report made to the Childrenʼs Division in this state or any state?
YES (Complete section below)
NO, I have not been substantiated as a perpetrator in any child abuse or neglect report.
DATE
CITY
STATE
COUNTY
CIRCUMSTANCES (Attach separate page, if necessary.)
The information provided is complete and accurate to the best of my knowledge. I understand it is unlawful to withhold or falsify information
required on this form. I grant permission to the Department of Social Services to obtain any and all information needed to process my request
and to use the information as permitted by law.
SIGNATURE OF APPLICANT (REQUIRED IN INK)
DATE
SIGNATURE OF REQUESTOR (Required in ink)
DATE
TITLE OF CHILD CARE PROVIDER
TELEPHONE
STATE AGENCY
STATE VENDOR OR CONTACT NO. (If applicable)
CHECK APPROPRIATE BOX
CHILD CARE RELATED EMPLOYMENT
DOH / CCB CHILD CARE BUREAU
SCHOOLS / PUBLIC AND PRIVATE
CHILD CARE RELATED VOLUNTEER
DMH / DMH VENDOR
CD CONTRACT PROVIDER
CD LICENSURE
HEALTH CARE
OTHER _______________________________
SEND FEE & FORM TO:
COMPLETE RETURN ADDRESS (REQUIRED ON EACH APPLICATION)
Complete your mailing label below
Missouri State Highway Patrol
Confidential Mail
Criminal Justice Information Services Division
P.O. Box 9500
AGENCY NAME
Jefferson City, MO 65102
Republic R-III School District
ATTENTION
Human Resources
ADDRESS
518 N Hampton
CITY, STATE, ZIP CODE
MO 821-0353 (2-10)
Republic MO 65738
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