Record Check Authorization (LP)

Contents -

Record Check Authorization (LP)

If this is a child care provider or a resident 16 years or older or otherwise requires a record check, complete the record check authorization information below. All fields are required in the person is 16 or older except for the Other Names fields. Note: If the Owner is an organization, this information would not be required.

Other Last Names Used: (separated by commas)

This field is used to capture any other last names used by the party other than the name entered.

Other First Names Used: (separated by commas)

This field is used to capture any other first names used by the party other than the name entered.

Date of Birth

Enter the date of birth using the following format MM/DD/YYYY.

SSN* (Social Security Number)

Enter the Social Security Number for the party.

Contact Phone*

Enter the home telephone number for the party in this field using the format ###-###-####.

Birth City*

Enter the name of the city in which the applicant was born in this field.

Birth State*

Select the name of the state in which the applicant was born in this field using the down arrow () next to the field. If the applicant was born in another country, select Out of Country in this field.

Conviction Question*

The following question requires a Yes or No answer.

"Has applicant ever been convicted or found by a court to have committed fraud, felony or an offense involving violence or unlawful sexual activity, or other bodily injury to another person, including, but not limited to abuse, neglect or sexual activity with a child?"

Authorization Signed?*

If the Record Check Authorization form contains a signature, enter Yes in this field. If no signature date has been entered, enter No in this field.

Date Authorized

Enter the date that appears on the Record Check Authorization form in the format MM/DD/YYYY. This field is required if the authorization has been signed.