County DFCS - State of Georgia Out of Home Care



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) ADDRESSES MUST GO BACK FIVE YEARS NO GAPSFIRST 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 CODEMONTH/CURRENTPREVIOUS ADDREESS CITY/STATE/ZIP CODEMONTH/YEARPREVIOUS ADDRESSCITY/STATE/ZIP CODEMONTH/YEARPREVIOUS ADDRESSCITY/STATE/ZIP CODEMONTH/YEARPREVIOUS ADDRESSCITY/STATE/ZIP CODEMONTH/YEARDATE OF BIRTHSSN#SEXCURRENT HOUSEHOLD MEMBERS ONLY (To be completed by Foster Care/Adoptions applicants ONLY. 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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