DHS Form 1200 is a form that must be completed by all U.S. citizens or permanent residents entering or reentering the United States. The form is used to collect information about you and your visit, including the purpose of your trip, your intended length of stay, and any other countries you have visited in the last five years. Completing this form correctly is important to ensure a smooth entry into the United States. If you have any questions about DHS Form 1200, please contact us for assistance.
| Question | Answer |
|---|---|
| Form Name | Form Dhs 1200 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | arkansas dhs forms online dhs 1200, how to fill dhs form, dhs 1200, dhs 1200 form |
State of Hawaii |
|
DEPARTMENT OF HUMAN SERVICES |
|
REQUEST FOR EXEMPTION
(from Criminal History Record and Background Check Standards)
Section I: Individual Seeking Exemption
Print Name:
|
Last |
First |
|
M.I. |
Signature |
|
|
|
|
Social Security No.: |
|
|
Birth Date: |
|
Home Address:
Mailing Address:
Home Telephone: |
|
Business Telephone: |
Section II: Reasons for Exemption
COMPLETE ALL OF THE FOLLOWING ITEMS. Use additional sheets of paper if necessary.
1.Identify the agency and/or client that you will serve as a direct service provider (or serve in direct contact):
2.Describe the type of service you would be providing for the agency and/or client:
3.Why do you believe an exemption should be given for your criminal conviction or confirmation of abuse? Explain:
4.Concerning your criminal conviction or confirmation of abuse, were there things about the commission of the crime or abuse that would demonstrate that it is unlikely to occur again? Explain:
DHS 1200 (REV. 10/15)
5.List all significant activities/dates since your criminal conviction or confirmation of abuse, such as employment, participation in therapy or education:
6.References. List your references below and provide telephone numbers where they may be contacted. In providing this information, you are consenting to the Department of Human Services or their designee, contacting these individuals for reference verification purposes. Written statements of support may also be submitted:
7. Other comments you may wish to make regarding your exemption request:
8.SEND COMPLETED REQUEST FOR EXEMPTION FORM TO:
Fieldprint, Inc.
12000 Commerce Parkway Suite 100
Mount Laurel, NJ 08054
DHS 1200 (REV. 10/15)