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Applicant Record Check Information


The information entered in this section of the Application is used to perform a Record Check on the applicant.
Applicant Name
The name will be carried forward from the entry made on the previous page.
Record Check Reason
Since this page occurs in the Registered Home Application flow, the reason is pre-populated with License Application/Reapplication.
Other Last Names Used:  (separated by commas)
This field is used to capture any other last names used by the applicant other than the name entered on the Applicant Information page.
Other First Names Used:  (separated by commas)
This field is used to capture any other first names used by the applicant other than the name entered on the Applicant Information page.
Date of Birth*
The date of birth will be carried forward from the person information.
SSN (Social Security Number)*
If a Social Security Number has been entered, it will be carried forward from the person information.  If not, the Social Security Number for the applicant is required on this page.
Contact Phone Number
The phone number will be carried forward from the entry made on the previous page; however, it may be changed if necessary.
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 this person ever been convicted or found by a court to have committed a felony, fraud, crime of violence, or unlawful activity, and/or had abuse or neglect substantiated against him/her?
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.
Authorized Date*
Enter the date that appears on the Record Check Authorization form in the format MM/DD/YYYY.


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Submitting Record Check Information