DPHHS-QAD/CRL-18 (Revision 3-10)
DEPARTMENT OF
PUBLIC HEALTH AND HUMAN SERVICES
STATE OF MONTANA
- RELEASE OF INFORMATION -
For Adult and Youth Care Facility Providers
Criminal / Protective Service / Motor Vehicle
Background Checks
PERSONAL INFORMATION
Section A – Current Information
Phone # ________________________
Legal Name: ______________________________________________________________________________________
(First)(Middle)(Maiden)(Last)
Aliases/Other Names Used: __________________________________________________________________________
Residential Address: ________________________________________________________________________________
(Street)(City) (State ) (Zip)
Mailing Address: ___________________________________________________________________________________
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(Street) |
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(City) |
(State ) |
(Zip) |
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Sex: [ |
] Male |
[ ] Female |
Date of Birth: _________________ |
Social Security #_________________________ |
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Section B – Past Residences |
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Within the last five (5) years, have you… |
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1. |
…lived in another state? |
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] Yes |
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] No |
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2. |
…lived on or do you now live in an area designated as an Indian reservation? |
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] Yes |
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] No |
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If you answered yes to the any of the above questions: |
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Please state where you have lived since turning 18 in the table below. |
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You will need to obtain an out of state background check or a tribal background check at your cost. |
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City |
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County |
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Reservation |
State |
Dates of Residency (From – To) |
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Section D – Employment Status
The facility that I am working / living at is:
Director Name / Facility Name: ___________________________________________________________________
Facility Mailing Address: ________________________________________________________________________
PLEASE COMPLETE BOTH SIDES OF THIS FORM
Section E – Authorization Statement and Signature
I, ____________________ (applicant name), am aware that __________________________________ (provider or its
authorized representative), has requested confidential information from the Montana Department of Public Health and Human Services, in accordance with 41-3-205(3)(o), MCA as part of a review of my personal background in connection with my status as a current or prospective employee of or volunteer for that entity.
I am aware that CFSD, DMV, and DOJ records may contain information that could adversely affect my employment or volunteer status and/or approval as outlined in ARM 37.95.161 and ARM 37.95.176. These records will relate to any substantiated report(s) of child abuse or neglect in Montana, criminal history records, and motor vehicle records. As a household member, I understand that I am also subject to the above requirements.
I am also aware that although the entities or individuals requesting and receiving confidential CFSD information are bound by law or agreement with DPHHS to protect or preserve its confidential nature, DPHHS has no ability or authority to ensure that confidentiality is maintained after this information is released by DPHHS.
In full acknowledgement of the above information and notice, I authorize CFSD to provide the requested confidential information to__________________________________________ (provider or its authorized representative), and I
hereby also release CFSD from any claims or causes of action which may subsequently arise from release of this confidential information.
NOTE: Any deletions or oversights may result in the denial of your application.
Signed: _______________________________________________________________ Date: ____________________
(To be signed in front of a notary)
TO BE COMPLETED BY A NOTARY PUBLIC:
Taken, sworn, and subscribed before me this ____________ day of _________________________ A.D. ____________
_________________________________________________________
Notary Public for the State of Montana
Residing at: _______________________________________________
My commission expires: _____________________________________