ADULT FAMILY HOME CERTIFICATION AGREEMENT
CHILDREN’S LONG TERM SUPPORT (CLTS) SOLE PROPRIETOR
Background Check Information
|* PLEASE TYPE OR PRINT CLEARLY* |
|* ILLEGIBLE OR INCOMPLETE APPLICATIONS WILL NOT BE PROCESSED* |
| |
|Last Name: | | First: | | Middle: | |
|Social Security Number: | - - |Date of Birth: |(Month/Day/Year) | |
|Drivers License Number | | | | |
|Previous Names, First and Last: | |
|Your Current Address/ Street: | |
|Current City, State, Zip Code: | |
|Home Phone: | |Cell Phone: | |Email Address: |
|List all addresses for the past 5 years: | |
| |
| |
|Have you or anyone in your home ever been arrested? | NO YES |
| If YES, who: | |
|Have you or anyone in your home had contact with any law enforcement agency? | NO YES |
|If YES, who: | |
|Please list law enforcement contacts: | |
| |
|I affirm that the information given in this application is accurate: |
| | | |
|CLTS Provider Signature | |Date |
* PLEASE RETURN TO cltswaiver@
|FOR ACS OFFICE USE: |
|Caregiver Background |__ No Criminal Record or __Results attached Staff initials: ________ |
|check/s completed (date): | |
|This person is: |
|__ approved to provide CLTS services |
|__ not approved to provide CLTS services |
|__ approved to provide CLTS services until (date) ____________________ and record rechecked at that time. Manager initials _______ |
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Division of Adult Community Services
Dane County Department of Human Services
1202 Northport Drive, Madison Wisconsin 53704 * 608-242-6200 * FAX: 608-242-6531
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