Georgia Form 5579 – Fill Out and Use This PDF

Georgia Department of Human Resources

RESIDENTIAL CHILD CARE

RECORDS CHECK APPLICATION (See Instructions on Back of Form)

2.Print Name ____________________________________________________________________________

	(Last)	(First)	(Middle)	(Maiden)		(Date of Birth)
________	______	__________________________			________________________
(Sex)	(Race)	(Social Security Number)				(Place of Birth)

_________ __________ ______________ _____________ __________________________

(Height) (Weight) (Color of Eyes) (Color of Hair) (Home Telephone)

__________________________________________________________________________________

(Mailing Address)

(City)

(State)

(Zip)

3.I hereby authorize the Department of Human Resources and my potential employer named below to receive any criminal history record information pertaining to me which may be in the files of any state or local criminal justice agency in Georgia. As required by Law, I have attached an affidavit disclosing the nature and date of any arrest, charge, or conviction, for the violation of any law in any state, except for motor vehicle parking violations.

___________________________________	_____________________________________
(Notary)	(Applicant Signature)
Notary Public ________________, Georgia	My Commission Expires: _________________
(County)	(Date)

TO BE COMPLETED BY OWNER/DIRECTOR OF RESIDENTIAL CHILD CARE FACILITY OR APPLICANT FOR LICENSE:

(PLEASE PRINT CLEARLY)

4. _______________________________________________________________________________________

(PRINT Name of Residential Child Care Facility) (PRINT RCC Address) (PRINT City/Zip Code of PCH)

_______________________________________________________________________________________

(PRINT mailing address, if different from RCC address)

(PRINT City/Zip Code/County Name)

5.THE RESIDENTIAL CHILD CARE FACILITY IDENTIFIED ABOVE: (CHECK ONE)

Is currently licensed.

Is applying for an initial (new) license at the above address.

6.My signature indicates that I, as DIRECTOR/OWNER, have verified the above information on the above applicant.

________________________________________	____________________________________________
(PRINT Name of Director/Owner)	(Telephone of Agency)
_______________________________________	____________________________________________
(Signature of Director/Owner)	(Date)

Form 5579 (Rev.4/18/08) YOU MAY DUPLICATE AND KEEP FOR YOUR RECORDS

Application Instructions

Do not have the Live Scan done before turning in your application package.

1.Please use a ball point pen, press firmly, and PRINT legibly.

2.Please indicate if you are a director/ manager, an owner or an employee (with a criminal history). You should check both owner and director/manager if you are both the administrator and the owner.

3.Print your full name, including your MAIDEN name. DO NOT use initials if your have a given name.

Print your date of birth. Print either: Male or Female.

Print your race: Black, White, or Other. Print your Social Security Number.

Print your place of birth: City or County, State and Country if not USA. Print your height.

Print your weight.

Print the color of your eyes: Do NOT abbreviate: Brown, Black, Grey, Blue, Green, or Hazel.

Print the color of your hair: DO NOT abbreviate: Brown, Black, Grey, Red, Blonde, or Bald. Print your home address.

Print your home telephone number.

4.ALL APPLICATIONS MUST BE NOTARIZED. Read the consent statement.

Sign your name as you would on a bank check or business letter.

DIRECTOR/OWNER WILL COMPLETE THE FOLLOWING

5.Record check results will be mailed to the address that is entered here. Print clearly and give complete mailing address.

Indicate name of your facility as it appears on your permit or permit application. Print the address of the Residential Child Care Facility.

Print the mailing address where the letter of determination is to be sent. Print the city/zip/county.

6.Check the correct box to indicate current licensure status for your Residential Child Care facility.

7.Director or Owner must sign his/her name as it would appear on a bank check or business letter.

8.This form must be completed and brought with you for Live Scans at 2 Peachtree or specified DHR-DFCS offices OR, if the Live Scan is done at a COGENT/GAPS location, this form must be mailed to:

Office of Investigative Services

Background Investigations Unit

2 Peachtree Street, N.W., Suite 30.482

Atlanta, GA. 30303-3142

9.If the Criminal Records Check Application is not received by OIS, you will not receive a determination letter.

10.This form should be sent to OIS before the fingerprinting at the COGENT/GAPS location is done.