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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