A clearance form is a document that authorizes the release of specific information to authorized individuals. The clearance form is also known as a 'release form'. Clearance forms are used by businesses and organizations to protect their confidential or sensitive information. The form must be completed and signed by the individual who has authorization to release the information. Fia is a popular online clearance form builder that allows businesses and organizations to create, manage, and share their clearance forms with ease. With Fia, you can quickly create custom clearance forms for your company or organization in just minutes. Plus, Fia offers free templates and tutorials so you can get started right away! Visit Fia today to learn more about how they can help you build custom clearance forms for your business or organization.
| Question | Answer |
|---|---|
| Form Name | Fia Clearance Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | Mecosta, Requestor, Osceola, DHS-194 |
REQUEST FOR CENTRAL REGISTRY CLEARANCE
Michigan Department of Human Services
I am requesting that DHS provide me with a Central Registry Clearance on myself.
** NOTE: PLEASE PRINT **
Today’s Date
Name
Birthdate |
Social Security Number |
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Current Mailing Address (Street No. and Name) |
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City |
State |
Zip Code |
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Current Phone Number
Other Name(s) By Which Known (Maiden Name, Previous Married Name(s), Other First or Last Name(s) Used)
If you are mailing this form to the DHS office, please attach copies of your Driver’s License or State of Michigan ID and your Social Security card and mail to your local DHS office – Mecosta and Osceola County residents, return form to:
MECOSTA / OSCEOLA DEPT. OF HUMAN SERVICES 800 WATERTOWER RD.
BIG RAPIDS, MI. 49307
If this request is made in person at the DHS office, please bring your Driver’s License or State of Michigan ID and your Social Security card. A copy machine is located in our lobby for your convenience to make copies of these to accompany this request form.
This clearance can not be completed without all of the requested information and copies of your Driver’s License or State of Michigan ID and your Social Security card.
If you are under the age of 18, a parent or guardian must sign the form for you.
Signature of Requestor |
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Signature of DHS Staff Person Completing Request |
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The Department of Human Services will not discriminate against any |
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AUTHORITY: State P.A. 238 of 1975, 722.627, Sec. 7(f) |
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individual or |
group because |
of race, |
sex, religion, age, |
national origin, |
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color, height, |
weight, marital |
status, |
disability or political |
beliefs. If you |
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RESPONSE: Voluntary |
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need help with reading, writing, hearing, etc., under the Americans with |
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PENALTY: Inappropriate release of this information is a misdemeanor. |
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Disabilities Act, you are invited to make your needs known to a DHS office |
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in your county. |
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