This form is to request a screening to for Child Protective Services history. AGENCY REQUESTING SCREENING INFORMATION NAME & JOB TITLE TEL # EMAIL 404-123-6789 JANEDOE@ABCAGENCY.COM JANE DOE-RECRUITER NAME OF AGENCY STREET ADDRESS CITY/STATE/ZIP CODE CPA AGENCY 123 WHEREEVER LANE ATLANTA, GA 12345 SCREENING RESULTS TO BE SENT TO NAME TEL # EMAIL SAME AS ABOVE SAME AS ABOVE SAME AS ABOVE NAME OF AGENCY STREET ADDRESS CITY/STATE/ZIP CODE SAME AS ABOVE SAME AS ABOVE SAME AS ABOVE INFORMATION ON PERSON TO BE SCREENED (APPLICANT) FIRST NAME MIDDLE NAME LAST NAME ELIZABETH DOE FOX MAIDEN NAME *If you have been married, you have to provide this OTHER NAMES USED IN THE PAST MILLER, DUNN, JONES LIZ information. CURRENT STREET ADDRESS CITY/STATE/ZIP CODE MONTH/YEAR-CURR ATLANTA, GA 12345 FULTON- 123 MAIN STREET PREVIOUS ADDRESS CITY/STATE/ZIP CODE MONTH/YEAR 456 MAIN STREET ATLANTA, GA 12345 10/2015-6/2017 PREVIOUS ADDRESS CITY/STATE/ZIP CODE MONTH/YEAR 789 MAIN STREET ATLANTA, GA 12345 8/2014-10/2015 PREVIOUS ADDRESS CITY/STATE/ZIP CODE MONTH/YEAR 654 MAIN STREET ATLANTA, GA 7/2013-8/2014- PREVIOUS ADDRESS CITY/STATE/ZIP CODE MONTH/YEAR 4321 MAIN STREET ATLANTA, GA 12345 6/2012-7/2013 DATE OF BIRTH SSN# SEX 1/2/1955 123-45-6789 FEMALE CURRENT HOUSEHOLD MEMBERS (To be completed by Foster Care/Adoptions applicants ONLY. NAME/ALIAS (First, Middle, Last) RELATIONSHIP DATE OF SSN # GENDER PREVIOUS DATE STATE(S) SPOUSE 2/5/1970 123-45-6789 FEMALE GA JOHN FOX MALE SON 3/2/1989 123-45-6789 FEMALE GA JAMES FOX MALE DAUGHTER 4/5/2002 N/A FEMALE GA JAMIE FOX MALE JOHN FOX JR SON 6/5/2016 N/A FEMALE GA MALE FEMALE MALE IN ORDER TO VERIFY THAT YOU ARE THE REQUESTING AGENCY, PLEASE SUBMIT A WRITTEN REQUEST ON AGENCY LETTERHEAD ALONG WITH THIS FORM TO THE GEORGIA CHILD PROTECTIVE SERVICES EMAIL
This form is to request a screening to for Child Protective Services history. AGENCY REQUESTING SCREENING INFORMATION NAME & JOB TITLE JANE DOE-RECRUITER TEL # 404-123-6789 EMAIL JANEDOE@ABCAGENCY.COM NAME OF AGENCY CPA AGENCY STREET ADDRESS 123 WHEREEVER LANE CITY/STATE/ZIP CODE ATLANTA, GA 12345 SCREENING RESULTS TO BE SENT TO NAME SAME AS ABOVE TEL # SAME AS ABOVE EMAIL SAME AS ABOVE NAME OF AGENCY SAME AS ABOVE STREET ADDRESS SAME AS ABOVE CITY/STATE/ZIP CODE SAME AS ABOVE INFORMATION ON PERSON TO BE SCREENED (APPLICANT) FIRST NAME ELIZABETH MIDDLE NAME DOE LAST NAME FOX MAIDEN NAME *If you have been married, you have to provide this information. MILLER, DUNN, JONES OTHER NAMES USED IN THE PAST LIZ CURRENT STREET ADDRESS 123 MAIN STREET CITY/STATE/ZIP CODE ATLANTA, GA 12345 MONTH/YEAR-CURR FULTON- PREVIOUS ADDRESS 456 MAIN STREET CITY/STATE/ZIP CODE ATLANTA, GA 12345 MONTH/YEAR 10/2015-6/2017 PREVIOUS ADDRESS 789 MAIN STREET CITY/STATE/ZIP CODE ATLANTA, GA 12345 MONTH/YEAR 8/2014-10/2015 PREVIOUS ADDRESS 654 MAIN STREET CITY/STATE/ZIP CODE ATLANTA, GA MONTH/YEAR 7/2013-8/2014- PREVIOUS ADDRESS 4321 MAIN STREET CITY/STATE/ZIP CODE ATLANTA, GA 12345 MONTH/YEAR 6/2012-7/2013 DATE OF BIRTH 1/2/1955 SSN# 123-45-6789 SEX FEMALE CURRENT HOUSEHOLD MEMBERS (To be completed by Foster Care/Adoptions applicants ONLY. NAME/ALIAS (First, Middle, Last) RELATIONSHIP DATE OF SSN # GENDER PREVIOUS STATE(S) DATE JOHN FOX SPOUSE 2/5/1970 123-45-6789 FEMALE MALE GA JAMES FOX SON 3/2/1989 123-45-6789 FEMALE MALE GA JAMIE FOX DAUGHTER 4/5/2002 N/A FEMALE MALE GA JOHN FOX JR SON 6/5/2016 N/A FEMALE MALE GA FEMALE MALE IN ORDER TO VERIFY THAT YOU ARE THE REQUESTING AGENCY, PLEASE SUBMIT A WRITTEN REQUEST ON AGENCY LETTERHEAD ALONG WITH THIS FORM TO THE GEORGIA CHILD PROTECTIVE SERVICES EMAIL
SAMPLE_CPS_Screening_Form_061318.docx