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 JANE DOE-RECRUITERTEL #404-123-6789EMAILJANEDOE@NAME OF AGENCYCPA AGENCYSTREET ADDRESS 123 WHEREEVER LANECITY/STATE/ZIP CODEATLANTA, GA 12345SCREENING RESULTS TO BE SENT TONAME SAME AS ABOVETEL #SAME AS ABOVEEMAILSAME AS ABOVENAME OF AGENCY SAME AS ABOVESTREET ADDRESS SAME AS ABOVECITY/STATE/ZIP CODESAME AS ABOVEINFORMATION ON PERSON TO BE SCREENED (APPLICANT)FIRST NAMEELIZABETHMIDDLE NAMEDOELAST NAMEFOXMAIDEN NAME *If you have been married, you have to provide this information. MILLER, DUNN, JONESOTHER NAMES USED IN THE PASTLIZCURRENT STREET ADDRESS123 MAIN STREETCITY/STATE/ZIP CODEATLANTA, GA 12345COUNTYFULTON- 7/2017-CURRENTPREVIOUS ADDREESS 456 MAIN STREETCITY/STATE/ZIP CODEATLANTA, GA 12345DATE10/2015-6/2017PREVIOUS ADDRESS789 MAIN STREETCITY/STATE/ZIP CODEATLANTA, GA 12345DATE8/2014-10/2015PREVIOUS ADDRESS654 MAIN STREETCITY/STATE/ZIP CODEATLANTA, GA 12345DATE7/2013-8/2014-PREVIOUS ADDRESS4321 MAIN STREETCITY/STATE/ZIP CODEATLANTA, GA 12345DATE6/2012-7/2013DATE OF BITH1/2/1955SSN#123-45-6789SEXFEMALECURRENT HOUSEHOLD MEMBERS (To be completed by Foster Care/Adoptions applicants ONLY. NAME/ALIAS (First, Middle, Last)RELATIONSHIPDATE OF BIRTHSSN # GENDER PREVIOUS STATE(S)DATEJOHN FOXSPOUSE2/5/1970123-45-6789 FORMCHECKBOX FEMALE FORMCHECKBOX MALEGA1970-CURRENTJAMES FOXSON3/2/1989123-45-6789 FORMCHECKBOX FEMALE FORMCHECKBOX MALEGA1989-CURRENTJAMIE FOXDAUGHTER4/5/2002N/A FORMCHECKBOX FEMALE FORMCHECKBOX MALEGAJOHN FOX JRSON6/5/2016N/A FORMCHECKBOX FEMALE FORMCHECKBOX MALEGA 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 APPLICANTDATE7/26/2017 ................
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