Form Dds 5088 – Fill Out and Use This PDF

ORI AR 920440Z

REQUEST FOR CRIMINAL RECORD CHECK

Obtain forms from: Arkansas Department of Human Services, Division of Developmental Disabilities Services (DDS) Licensure and Certification, PO Box 1437, Slot N203, Little Rock, AR 72203-1437, (501) 320-6408

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Type of Provider: Licensed DDTCS ___ Certified Early Intervention ___ Certified Waiver___ New ___

Provider submitting form: ___________________________________ _________________________________________ __________________________________

Name of Provider	Address	City/Zip
_______________________________________________________	________________________________________________________
Name of Provider Contact Person		Telephone number (include Area Code)

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Name of person		______________________________________________________________________________________________________________________
to be checked:			Last Name	First Name	Middle Name
Current address		______________________________________________________________________________________________________________________
		Street			City	State	ZIP Code
_______________________________			_______________________________		___________________________		__________________________
	Maiden Name		Aliases		Date of Birth (month/day/year)		Telephone
___ ___ ___-___ ___- ___ ___ ___ ___			______________	________	__________________________		_________________
Social Security Number			Race	Sex (M/F)	Driver's License Number		State of Issuance
Note:	The name, address, and date of birth listed above must appear on a valid identification document issued by a government entity.

Please list the document used if not the person's driver's license: ______________________________________________________________________________

The person listed above must list all past felony or misdemeanor charges(s) for which he/she was found guilty of or to which he/she pled guilty or nolo contendere:

Date of charge	Location	Description of charge	Sentence/Disposition
________________	__________________	____________________________________	_____________________________
________________	__________________	____________________________________	_____________________________
________________	__________________	____________________________________	_____________________________

Notice to Applicant: By signing this form you give consent for the Arkansas State Police to release your criminal history report to the employer listed above and to the Division of Developmental Disability Services (DDS). Pursuant to Arkansas Code Ann. § 20-38-101, DDS will issue a letter of determination to the employer stating your employment eligibility based on your criminal history report. The employer must then provide you with a copy of the determination letter. Prior to the receipt of the determination letter, the employer may choose to deny any employee unsupervised access to a person to whom the employer provides care. You may obtain a copy of your criminal history report from the employer. You must direct any challenges to the accuracy of the report to the Arkansas State Identification Bureau, Arkansas State Police, #1 State Police Plaza Drive, Little Rock, Arkansas 72209 (501) 618-8500.

Statement of Oath: I state on oath that the representations made herein are true, complete, and correct.

Providing false information on this form is a violation of Arkansas law and is punishable as set forth in Arkansas Code Annotated § 5-53-103.

______________________________________________	____________________
Signature of Applicant/Employee	Date

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Notarization:	State of Arkansas	County of _____________________	Subscribed and sworn to before me, a Notary Public, in and for the county and state
noted above this the _________day of ____________________, _________.			___________________________________________________
			Notary Public

My commission expires on ___________________________, (year)____________.

(Notary Seal)

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FOR ARKANSAS STATE POLICE ONLY

_________82005 Civil Records Check $25 via postal mail ($22.00 via online services)	_________80007 & 80006 FBI Records Check $16.50
Form DDS-5088 State