Get MI BCAL-1326A 2016-2023
AFC/HFA LICENSING RECORD CLEARANCE REQUEST Administrator Responsible Person or Adult Member of Household Only STATE OF MICHIGAN Department of Licensing and Regulatory Affairs Bureau of Communit and Health S stems DIRECTIONS FOR COMPLETING FORM Type or print CLEARLY so that the information provided can be read. Mail the completed form to the Bureau of Community and Health Systems BCHS at the address below. Michigan Department of Licensing and Regulatory Affairs P O Box 30664 Lansing MI 48909 Licensin Consultant if known REQUESTOR INFORMATION LICENSEE/APPLICANT NAME NAME OF FACILITY COUNTY LICENSE NUMBER AFC Group Home AFC Family Home THE PERSON BEING CLEARED IS CHECK ONLY ONE BOX Note Administrators or Responsible Persons are to be cleared through the Workforce Background Check Program. Website https //miltcpartnership.org/ Responsible Person Adult Member of Household CLEARANCE INFORMATION PRINT CLEARLY NAME Last First Middle Jr. Michigan Department of Licensing and Regulatory Affairs P O Box 30664 Lansing MI 48909 Licensin Consultant if known REQUESTOR INFORMATION LICENSEE/APPLICANT NAME NAME OF FACILITY COUNTY LICENSE NUMBER AFC Group Home AFC Family Home THE PERSON BEING CLEARED IS CHECK ONLY ONE BOX Note Administrators or Responsible Persons are to be cleared through the Workforce Background Check Program. Website https //miltcpartnership.org/ Responsible Person Adult Member of Household CLEARANCE INFORMATION PRINT CLEARLY NAME Last First Middle Jr. II etc. MARITAL STATUS Married Divorced Single Widowed GENDER SOCIAL SECURITY NUMBER ALSO KNOWN AS Aliases Maiden Name Previous Married Names ADDRESS Street Number and Name CITY BIRTH DATE MICHIGAN DRIVERS LICENSE OR STATE ID NUMBER MI ZIP CODE HOW LONG HAVE YOU LIVED IN MICHIGAN PHONE NUMBER RACE HEIGHT OTHER STATES RESIDED IN DURING PAST 5 YEARS HAVE YOU EVER Been convicted of a crime felony or misdemeanor NO YES If yes explain Type Location and Date of Conviction s for additional space attach separate sheet SIGNATURE OF PERSON TO BE CLEARED DATE CENTRAL RECORDS CLEARANCE Licensing Use Only SECRETARY OF STATE DISCREPANCY For Famil Home A licants Onl YES INITIALS/CLEARANCE DATE ADDRESS ON MICHIGAN PUBLIC SEX OFFENDER REGISTRY NA PREVIOUS REGISTRATION/LICENSE ACTIVE CLOSED For BCHS Use Only DISCIPLINARY ACTION AUTHORITY 1978 PA 368 / 1979 PA 218 COMPLETION Required CONSEQUENCE Licensure ma be denied or revoked. BCAL-1326A-NFP Rev. 2-17 Previous edition cannot be used. MS Word LARA is an equal opportunity employer/program.
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