Form CCLU2 "Nh Child Abuse and Neglect Central Registry Name Search Authorization" - New Hampshire

What Is Form CCLU2?

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

Form Details:

  • Released on December 1, 2020;
  • The latest edition provided by the New Hampshire Department of 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 CCLU2 by clicking the link below or browse more documents and templates provided by the New Hampshire Department of Health and Human Services.

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Download Form CCLU2 "Nh Child Abuse and Neglect Central Registry Name Search Authorization" - New Hampshire

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STATE OF NEW HAMPSHIRE
Form CCLU 2
Department of Health and Human Services
December 2020
Child Care Licensing Unit
NH CHILD ABUSE AND NEGLECT CENTRAL REGISTRY NAME SEARCH AUTHORIZATION
CHILD CARE LICENSING RELEASE OF INFORMATION
I hereby request the NH Department of Health and Human Services (NH DHHS) to conduct a name search
to determine if I am listed on the Department's Central Registry of founded reports of child abuse and ne-
glect. My full legal name, other names I have used in the past, and other identifying information are listed
below.
:
(please print legibly)
CURRENT FULL LEGAL NAME
(
)
,
:
(if applicable)
OTHER NAMES
ALIASES
I HAVE USED
INCLUDING MAIDEN NAME
:
:
DATE OF BIRTH
TELEPHONE NUMBER
month
day
year
:
CURRENT ADDRESS
number and street name
mailing address if different
city or town
state
zip code
PROGRAM:
LICENSE
:
NAME OF CHILD CARE
NUMBER
number and street name
city or town
state
zip code
I acknowledge that the results of this search can only be released to myself or the Department of
Health and Human Services pursuant to RSA 170-E for the purpose New Hampshire Child Day Care
Licensing.
S
:
D
:
IGNATURE
ATE
Sign in the presence of a notary
NOTARY ACKNOWLEDGEMENT
In witness whereof I hereunto set my official seal.
State of:
County of:
Subscribed and sworn before me on this
day of
,
in the year
by
(name of person being checked)
Personally known
Produced Identification
Signature of notary:
My commission expires:
For official use only
In order to process this request please mail form to:
Child Care Licensing Unit
Department of Health and Human Services
129 Pleasant Street Concord, NH 03301
December 2020
STATE OF NEW HAMPSHIRE
Form CCLU 2
Department of Health and Human Services
December 2020
Child Care Licensing Unit
NH CHILD ABUSE AND NEGLECT CENTRAL REGISTRY NAME SEARCH AUTHORIZATION
CHILD CARE LICENSING RELEASE OF INFORMATION
I hereby request the NH Department of Health and Human Services (NH DHHS) to conduct a name search
to determine if I am listed on the Department's Central Registry of founded reports of child abuse and ne-
glect. My full legal name, other names I have used in the past, and other identifying information are listed
below.
:
(please print legibly)
CURRENT FULL LEGAL NAME
(
)
,
:
(if applicable)
OTHER NAMES
ALIASES
I HAVE USED
INCLUDING MAIDEN NAME
:
:
DATE OF BIRTH
TELEPHONE NUMBER
month
day
year
:
CURRENT ADDRESS
number and street name
mailing address if different
city or town
state
zip code
PROGRAM:
LICENSE
:
NAME OF CHILD CARE
NUMBER
number and street name
city or town
state
zip code
I acknowledge that the results of this search can only be released to myself or the Department of
Health and Human Services pursuant to RSA 170-E for the purpose New Hampshire Child Day Care
Licensing.
S
:
D
:
IGNATURE
ATE
Sign in the presence of a notary
NOTARY ACKNOWLEDGEMENT
In witness whereof I hereunto set my official seal.
State of:
County of:
Subscribed and sworn before me on this
day of
,
in the year
by
(name of person being checked)
Personally known
Produced Identification
Signature of notary:
My commission expires:
For official use only
In order to process this request please mail form to:
Child Care Licensing Unit
Department of Health and Human Services
129 Pleasant Street Concord, NH 03301
December 2020