Form Cfs 689 – Fill Out and Use This PDF

CFS 689

6/2001State of Illinois

Department of Children and Family Services

AUTHORIZATION FOR BACKGROUND CHECK

Child Abuse and Neglect Tracking System (CANTS)

For Programs NOT Licensed by DCFS

NOTE: Do not use this form if you are an applicant for licensure or an employee/volunteer of a licensed child care facility. Please contact your licensing representative.

Name:

	Last				First		Middle
Date of Birth:				Gender (circle): Male	Female	Race:
Current Address:
				Street/Apt #
			City		State		Zip Code

List all addresses at which you have resided in the past five years:

List maiden name and/or all other names by which you have been known: (last, first, middle)

I hereby authorize the Illinois Department of Children and Family Services to conduct a search of the Child Abuse and Neglect Tracking system (CANTS) to determine whether I have been a perpetrator of an indicated incident of child abuse and/or neglect or involved in a pending investigation. I further consent to the release of this information to the agency listed below.

			Mail this request to:
			Department of Children and Family Services
			406 E. Monroe – Station # 30
	Signed	Date
			Springfield, IL 62701

Please type, use bold letters or label:

(Agency Name)

(Contact Person)

(Address)

(City/State/Zip)

(Submitting Agency Fax Number): 618.692.0685