Form 2602 PDF Details

In the realm of child care provision within New Hampshire, the need for ensuring the safety and wellbeing of children cannot be overstated. This underlying premise conspicuously underscores the significance of the Form 2602, a crucial document emanating from the efforts of the New Hampshire Department of Health and Human Services, particularly its Division for Children, Youth & Families. Designed as a Criminal History Record Information Authorization License Exempt Child Care Form, it meticulously bridges a critical gap in safeguarding measures by facilitating a thorough background check for individuals seeking to engage in child care activities that are exempt from licensure. The form, bearing a nominal fee for the processing of either Livescan or inked fingerprints, is categorical in its requirement for new applicants to undergo fingerprinting, whereas renewals are exempt. With precise fields to be filled out, ranging from personal identification details to consent for the release of any criminal record convictions, the importance of accuracy and truthfulness is reinforced by the imposition of penalties for unsworn falsification. Furthermore, the form also extends the provision for the designation of a recipient other than oneself, should there be a need for the criminal records to be dispatched directly to an entity like the NH Division for Children, Youth and Families Bureau of Child Development. Evidently, Form 2602 is not just a procedural necessity, but a cornerstone in the edifice of child care security and assurance, within the state of New Hampshire.

QuestionAnswer
Form NameForm 2602
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesstate of new hampshire criminal release form, state of new hampshire corie form, RSA, concord nh xriminal release form

Form Preview Example

 

STATE OF NEW HAMPSHIRE

 

DEPARTMENT OF HEALTH AND HUMAN SERVICES

 

DIVISION FOR CHILDREN, YOUTH & FAMILIES

 

129 PLEASANT STREET, CONCORD, NH 03301-3857

Nicholas A. Toumpas

603-271-4451 1-800-852-3345 Ext. 4451

FAX: 603-271-4729 TDD Access: 1-800-735-2964

Commissioner

 

Maggie Bishop

 

Director

 

NEW HAMPSHIRE HEALTH AND HUMAN SERVICES CRIMINAL HISTORY RECORD INFORMATION AUTHORIZATION

LICENSE EXEMPT CHILD CARE FORM NH RSA 170-E:4

LIVESCAN-$16.50

OR

INKED-$16.50

 

MUST SELECT ONE

OR

APPLICANTS ARE RESPONSIBLE FOR THIS FEE

NEW APPLICANT (Fingerprints are required)

RENEWAL (Fingerprints NOT required)

SECTION I

PLEASE TYPE OR PRINT CLEARLY, ALL INFORMATION IN THIS SECTION MUST BE COMPLETED

NAME

LAST

MAIDEN/ALAIS

FIRST

MI

ADDRESS

 

 

 

 

 

 

 

STREET

CITY

STATE

ZIP CODE

DATE OF BIRTH

 

HAIR COLOR

 

EYE COLOR

 

SEX

 

DRIVER LICENSE NUMBERSTATE

My signature below certifies I am the individual listed above and that the information provided is true.

YOUR SIGNATURE:

 

DATE

 

Signed under penalty of unsworn falsification pursuant to NH RSA 641:3.

SECTION II

IF RECORD IS TO BE MAILED TO YOU, OR RECEIVED BY SOMEONE OTHER THAN YOURSELF,

ALL OF SECTION II MUST BE COMPLETED

I hereby authorize the release of my criminal record conviction(s), if any, to the following:

NH Division for Children, Youth and Families Bureau of Child Development

129 Pleasant Street, Concord NH 03301

YOUR SIGNATURE

 

DATE

 

NOTARY ‘S SIGNATURE

DATE

 

 

(AFFIX SEAL)

 

(COMM. EXP)

 

 

 

DATE

SIGNATURE OF PERSON/FIRM TO RECEIVE RECORD

 

 

NOTE: Make checks payable to: State of NH – Criminal Records.

Applicant fingerprint card must be submitted at the same time as payment and this form.

Form 2602

PD 12-34

 

July 2012

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Tips on how to complete state of new hampshire criminal release form part 1

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NOTE Make checks payable to State, PD July, and Form in state of new hampshire criminal release form

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