Form CFS717-E "Authorization for Background Checks for Direct Child Welfare Services Employee Licensure Board" - Illinois

What Is Form CFS717-E?

This is a legal form that was released by the Illinois Department of Children and Family Services - a government authority operating within Illinois. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2001;
  • The latest edition provided by the Illinois Department of Children and Family Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a fillable version of Form CFS717-E by clicking the link below or browse more documents and templates provided by the Illinois Department of Children and Family Services.

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Download Form CFS717-E "Authorization for Background Checks for Direct Child Welfare Services Employee Licensure Board" - Illinois

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Illinois Department of Children and Family Services
CFS 717-E
AUTHORIZATION FOR BACKGROUND CHECKS
02/01
FOR DIRECT CHILD WELFARE SERVICES EMPLOYEE LICENSURE BOARD
PLEASE READ INSTRUCTIONS ON REVERSE SIDE
PRINT ALL INFORMATION IN INK
PERSONAL INFORMATION
Name (Last, First, Middle)
Maiden and/or Any Names Formerly Used (Last, First, Middle)
(If no other names, write “None”
Home Telephone Number (Including Area Code)
Social Security Number
Drivers License #
State
Current Address: (Street/Apt.#/City/County/State/Zip Code)
List all previous addresses for the past five years (Street/Apt. #/City/County/State/Zip Code)
Dates (From/To)
Date of Birth
Age
Place of Birth
Citizenship
Sex
Height
Weight
Hair
Eyes
Skin
Race
(Month/Date/Year)
(County/State)
(Country)
(Ft. In.)
(Lbs.)
(Color)
(Color)
Tone
M
F
Have you ever pled guilty to or been found guilty of any criminal offense or convicted of other than a minor traffic violation?
Yes
No
If yes, explain below (use additional space on reverse if necessary).
AUTHORIZATION / CERTIFICATION
I AUTHORIZE the Illinois Department of Children and Family Services (DCFS) to conduct the following criminal and child abuse background checks:
The Child Abuse and Neglect Tracking System to determine whether I have been a perpetrator in an “indicated” incident of child abuse or
neglect pursuant to the Abused and Neglected Child Reporting Act.
U.S. Justice Department and Illinois State Police records to determine whether I have ever been charged with a crime and, if so, the
disposition of those charges.
Statewide Child Sex Offender Registry.
I understand that the child abuse and neglect background check and the criminal history check will be used for considering my candidacy for Board
Membership appointment to the Child Welfare Direct Service Employee Licensure Board.
If I am appointed a member of the Child Welfare Direct Service Employee Licensure Board, I further authorize the Department to periodically conduct the
above searches during the course of my tenure.
I understand that information obtained as a result of my authorizing these background checks is confidential.
I further certify that the information provided on this form is true and correct.
I acknowledge that falsification of any information provided herein and/or the result of the background checks may be full and sufficient grounds to deny
my Board Membership.
Signature
Date
Illinois Department of Children and Family Services
CFS 717-E
AUTHORIZATION FOR BACKGROUND CHECKS
02/01
FOR DIRECT CHILD WELFARE SERVICES EMPLOYEE LICENSURE BOARD
PLEASE READ INSTRUCTIONS ON REVERSE SIDE
PRINT ALL INFORMATION IN INK
PERSONAL INFORMATION
Name (Last, First, Middle)
Maiden and/or Any Names Formerly Used (Last, First, Middle)
(If no other names, write “None”
Home Telephone Number (Including Area Code)
Social Security Number
Drivers License #
State
Current Address: (Street/Apt.#/City/County/State/Zip Code)
List all previous addresses for the past five years (Street/Apt. #/City/County/State/Zip Code)
Dates (From/To)
Date of Birth
Age
Place of Birth
Citizenship
Sex
Height
Weight
Hair
Eyes
Skin
Race
(Month/Date/Year)
(County/State)
(Country)
(Ft. In.)
(Lbs.)
(Color)
(Color)
Tone
M
F
Have you ever pled guilty to or been found guilty of any criminal offense or convicted of other than a minor traffic violation?
Yes
No
If yes, explain below (use additional space on reverse if necessary).
AUTHORIZATION / CERTIFICATION
I AUTHORIZE the Illinois Department of Children and Family Services (DCFS) to conduct the following criminal and child abuse background checks:
The Child Abuse and Neglect Tracking System to determine whether I have been a perpetrator in an “indicated” incident of child abuse or
neglect pursuant to the Abused and Neglected Child Reporting Act.
U.S. Justice Department and Illinois State Police records to determine whether I have ever been charged with a crime and, if so, the
disposition of those charges.
Statewide Child Sex Offender Registry.
I understand that the child abuse and neglect background check and the criminal history check will be used for considering my candidacy for Board
Membership appointment to the Child Welfare Direct Service Employee Licensure Board.
If I am appointed a member of the Child Welfare Direct Service Employee Licensure Board, I further authorize the Department to periodically conduct the
above searches during the course of my tenure.
I understand that information obtained as a result of my authorizing these background checks is confidential.
I further certify that the information provided on this form is true and correct.
I acknowledge that falsification of any information provided herein and/or the result of the background checks may be full and sufficient grounds to deny
my Board Membership.
Signature
Date
INSTRUCTIONS FOR COMPLETION
PRINT ALL INFORMATION
In ink.
Name
All current and former names used by the individual must be included. If no other names, write “none.”
THIS FORM WILL NOT BE PROCESSED WITHOUT A COMPLETE SOCIAL SECURITY NUMBER.
Social Security Number
Address
List current and all addresses, including county and state, where the applicant has lived in the past five years
Identifying Information
All identifying information must be accurate and complete.
Applicant must answer the question, “Have you ever pled guilty to or been found guilty of any criminal offense or convicted of other than
a minor traffic violation?” If yes, an explanation must be provided, complete with date(s) of the incident(s).
Applicant must sign and date the authorization form.
AUTHORIZATION / CERTIFICATION
Additional space, if needed:
Mail to:
Department of Children and Family Services
Division of Training and Development Services
Attn: Child Welfare Employee Licensure Program
406 East Monroe, Station 122
Springfield, IL 62701
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