Free http://www.cdhs.state.co.us/ea/PDFs/Individual.pdf - Colorado

STATE OF COLORADO

OFFICE OF EMPLOYMENT AND REGULATORY AFFAIRS Jenise May, Deputy Executive Director STATEWIDE SERVICES Matthew Flora, Director nd 3550 West Oxford Avenue, 2 Floor Denver, Colorado 80236 Phone 3038667100 TDD 3038667105 FAX 3038667177 www.cdhs.state.co.us

Bill Ritter Jr. Governor Karen L. Beye Executive Director

BACKGROUND INVESTIGATION UNIT INDIVIDUAL INQUIRY FORM
One of the following must be marked in order for BIU to process your request: Volunteer Foster Care Other (Explain) Employment Adoption

Please note: Your signature must be notarized and accompanied by a check or money order for $30.00 made payable to: CDHS, BIU, Records & Reports, 3550 W. Oxford Ave., Denver, CO 80236.
INDIVIDUAL MAKING REQUEST _________________________ First Name _________________________ Date of Birth PLEASE PRINT LEGIBLY __________________ Middle Name ____________ Sex: M/F _________________________ _________________________ Last Name Alias/Maiden Name _______________________ Race _________________________ Social Security Number

____________________________________________ Current Address ____________________________________________ Mailing Address ____________________________________________ Previous Address

____________________________________ ____________________ City/State/Zip Code Phone Number ____________________________________ City/State/Zip Code ____________________________________ City/State/Zip Code

SPOUSE/FORMER SPOUSE/PARENT(S) OF YOUR CHILDREN (Add additional names on a separate sheet of paper) _________________________ First Name _________________________ Date of Birth __________________ Middle Name ____________ Sex: M/F _________________________ _________________________ Last Name Alias/Maiden Name _______________________ Race _________________________ Social Security Number

CHILDREN ­ Use full names. (Add additional children on a separate sheet of paper)

1) 2) 3) 4)

_____________________________________________ Complete Name _____________________________________________ Complete Name _____________________________________________ Complete Name _____________________________________________ Complete Name

____________________________ Date of Birth ____________________________ Date of Birth ____________________________ Date of Birth ____________________________ Date of Birth

______________ Sex: M/F ______________ Sex: M/F ______________ Sex: M/F ______________ Sex: M/F

Any person who willfully permits or who encourages the release of data or information related to child abuse or neglect contained in TRAILS to persons not permitted access to search information commits a class 1 misdemeanor pursuant to §18 1.3501, C.R.S.

Signature of Individual (If under the age of 18, parent signature required.)

Date of Request

Notary Statement:

STATE of COUNTY of

_________________ _________________

Subscribed and sworn to before me this ________ day of _____________, ________.

My Commission Expires: ________________________

Notary Seal:

____________________________________________ Signature of Notary

If you wish for the background check results to be sent to a representative or agency other than yourself, please complete the following Waiver and Authorization.

WAIVER AND AUTHORIZATION TO RELEASE INFORMATION
I authorize the Colorado Department of Human Service, Background Investigation Unit (CDHSBIU) to release the results of the background check to the representative and/or agency listed below.
RELEASE INFORMATION TO: PLEASE PRINT LEGIBLY

Agency/Company Name: Name Of Individual: Mailing Address: City State Zip Code Phone Number

_______________________________________________________ Signature of Individual (If under the age of 18, parent signature required.)
Rev. 8/12/08

________________________ Date