County DFCS - Georgia Hope Inc.



This form is to request a screening to check for Child Protective Services history.AGENCY REQUESTING SCREENING INFORMATIONNAME & JOB TITLE TEL #EMAILNAME OF AGENCYSTREET ADDRESS CITY/STATE/ZIP CODESCREENING RESULTS TO BE SENT TONAME TEL #EMAILNAME OF AGENCY STREET ADDRESS CITY/STATE/ZIP CODEINFORMATION ON PERSON TO BE SCREENED (APPLICANT)FIRST NAMEMIDDLE NAMELAST NAMEMAIDEN NAME *If you have been married, you have to provide this information.OTHER NAMES USED IN THE PASTCURRENT STREET ADDRESSCITY/STATE/ZIP CODECOUNTYPREVIOUS ADDREESS CITY/STATE/ZIP CODEDATEPREVIOUS ADDRESSCITY/STATE/ZIP CODEDATEPREVIOUS ADDRESSCITY/STATE/ZIP CODEDATEPREVIOUS ADDRESSCITY/STATE/ZIP CODEDATEDATE OF BITHSSN#SEXCURRENT HOUSEHOLD MEMBERS (To be completed by Foster Care/Adoptions applicants ONLY. DFCS or CPA Please include other states and dates the household member has lived in the previous 5 years).NAME/ALIAS (First, Middle, Last)RELATIONSHIPDATE OF BIRTHSSN # GENDER PREVIOUS STATE(S)DATE FORMCHECKBOX FEMALE FORMCHECKBOX MALE FORMCHECKBOX FEMALE FORMCHECKBOX MALE FORMCHECKBOX FEMALE FORMCHECKBOX MALE FORMCHECKBOX FEMALE FORMCHECKBOX MALE FORMCHECKBOX FEMALE FORMCHECKBOX MALEIN ORDER TO VERIFY THAT YOU ARE THE REQUESTING AGENCY, PLEASE SUBMIT A WRITTEN REQUEST ON AGENCY LETTERHEAD ALONG WITH THIS FORM TO THE GEORGIA CHILD PROTECTIVE SERVICES EMAILSIGNATURE OF APPLICANTDATE ................
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