Form 3017 "Request for the Criminal History and Central Registry Checks Required for an Administrator's License" - Texas

What Is Form 3017?

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

Form Details:

  • Released on February 1, 2018;
  • The latest edition provided by the Texas Health and Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form 3017 by clicking the link below or browse more documents and templates provided by the Texas Health and Human Services.

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Download Form 3017 "Request for the Criminal History and Central Registry Checks Required for an Administrator's License" - Texas

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Form 3017
February 2018-E
Request for the Criminal History and Central Registry Checks Required for an Administrator's License
Use this form to request the Criminal History Check and the Central Registry Check that are required when applying for or
renewing an administrator's license.
Instructions: Complete all sections of this form and submit it with either Form 3014, Administrator License - Renewal or Status
Change, or Form 3015, Application for a Child-Care Administrator License or a Child-Placing Agency Administrator License.
Please make checks or money orders payable to Texas Health and Human Services.
Directions: Mail this form and either Form 3014 or Form 3015 to:
Texas Health and Human Services Commission
Administrator Licensing
RCCL Mail Code 1732, P.O. Box 16017
Houston, TX 77222
If you have questions, contact the Administrator Licensing Office at 713-696-7119 or CCLLICADM@hhsc.state.tx.us.
Applicant’s Information
First Name:
Middle Name (spell out completely):
Last Name:
List any other names you use or have used in the past, including married and maiden names, below. If you do not provide every
name that you have used, you may receive inaccurate results:
Other First Name:
Other Middle Name (spell out completely):
Other Last Name:
Physical Home Address (No P.O. Box Numbers):
City:
County:
State:
ZIP Code:
Contact Phone Number (including area code):
Date of Birth:
Male
Female
Email Address:
Driver's License Number or State-Issued ID (Number and State):
Social Security Number:
List any other city in Texas where you have been a resident and any addresses, including county, where you have lived outside of Texas in the
previous five years:
Race:
White
Black
Asian/Pacific Islander
American Indian/Alaskan Native
Ethnicity (must accompany race):
Hispanic
Other:
Form 3017
February 2018-E
Request for the Criminal History and Central Registry Checks Required for an Administrator's License
Use this form to request the Criminal History Check and the Central Registry Check that are required when applying for or
renewing an administrator's license.
Instructions: Complete all sections of this form and submit it with either Form 3014, Administrator License - Renewal or Status
Change, or Form 3015, Application for a Child-Care Administrator License or a Child-Placing Agency Administrator License.
Please make checks or money orders payable to Texas Health and Human Services.
Directions: Mail this form and either Form 3014 or Form 3015 to:
Texas Health and Human Services Commission
Administrator Licensing
RCCL Mail Code 1732, P.O. Box 16017
Houston, TX 77222
If you have questions, contact the Administrator Licensing Office at 713-696-7119 or CCLLICADM@hhsc.state.tx.us.
Applicant’s Information
First Name:
Middle Name (spell out completely):
Last Name:
List any other names you use or have used in the past, including married and maiden names, below. If you do not provide every
name that you have used, you may receive inaccurate results:
Other First Name:
Other Middle Name (spell out completely):
Other Last Name:
Physical Home Address (No P.O. Box Numbers):
City:
County:
State:
ZIP Code:
Contact Phone Number (including area code):
Date of Birth:
Male
Female
Email Address:
Driver's License Number or State-Issued ID (Number and State):
Social Security Number:
List any other city in Texas where you have been a resident and any addresses, including county, where you have lived outside of Texas in the
previous five years:
Race:
White
Black
Asian/Pacific Islander
American Indian/Alaskan Native
Ethnicity (must accompany race):
Hispanic
Other:
Form 3017
Page 2 / 02-2018-E
Operation's Information
Operation Name:
Operation Number:
Operation Address:
Administrator's License Number:
Your Role at the Operation:
Administrator or Backup Administrator
Staff
Not Affiliated with an Operation
Other:
To apply for or renew an administrator’s license, do as follows:
• Obtain a Criminal History Check and Central Registry Check through HHSC;
• Obtain an FBI fingerprint check; and
• Pay a $2 fee, if you have not received a background check through Child Care Licensing in the past 24 months. Make
your payment payable to Texas Health and Human Services Commission.
You are not required to complete a new fingerprint-based criminal history check if:
• You have a fingerprint-based criminal history record from a background check that is accessible to HHSC through the
Department of Public Safety's (DPS's) clearinghouse, and the date of fingerprinting is not more than 24 months old; or
• You have a fingerprint-based criminal history check on record with HHSC that was submitted within 24 months of the
newest request.
Status of FBI Fingerprint Check
Check one of the following:
I must obtain an FBI fingerprint check.
I already have an FBI fingerprint check on record that is accessible to HHSC through the Department of Public Safety (DPS),
and it has not been more than 24 months since my previous Criminal History Check.
I already have an FBI fingerprint check on record with HHSC and it has not been more than 24 months since my previous
DPS Criminal History Check.
Title 40 of the Texas Administrative Code, §§745.8933 and 745.8993, require a licensed administrator or applicant to provide
identifying information that will be used to check for any criminal history that is a violation of law or HHSC rule and to check
DFPS’s central registry of abuse and neglect. It may be necessary to obtain additional information if you do not live in Texas or
may have a criminal history in another state. You will be notified if the results of the check violate law or rule.
Privacy Statement
HHSC values your privacy. For more information, read our privacy policy online at:
https://hhs.texas.gov/policies-practices-
privacy#security.
Signature
I verify that the information on this form contains no willful misrepresentation and that the information given is true and complete
to the best of my knowledge.
I understand that HHS may contact others and, at any time, seek proof of any information contained here.
I understand that any willful misrepresentation or failure to provide identifying information within the stated time limit may result in
adverse action.
Signature of Licensed Administrator or Applicant
Date Signed
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