Follow the steps to complete the checklist accurately.

1. Press the ‘Get Form’ button to obtain the checklist and open it in your preferred online editor.
2. In Section A, provide the name of the agency or facility requesting the check, including its street address, CDHS license number, email address, and phone number. All fields marked as 'REQUIRED' must be filled out accurately.
3. Navigate to Section B and enter the applicant's information. This includes the first name, middle name, last name, social security number, date of birth, sex, race/ethnicity, and current address. Use clear and concise terms for any previous names used and indicate whether you have lived in any other states in the past five years.
4. If you answered 'Yes' to living in another state, proceed to Section C. Here, list all states you have lived in during the past five years, the addresses associated with those residences, and the completion dates for each of the required background checks: State Criminal History Check, State Child Abuse and Neglect Registry Check, and State Sex Offender Registry Check.
5. Continue completing Section C for all states you have lived in. If you’ve lived in more than seven states, ensure you submit an additional copy of these details on a new page, allowing adequate space for all entries.
6. Once information is filled in Section D, summarize the previous residence information, including each state, the residency duration, and completion dates of the necessary background checks.
7. Finally, complete Section E by signing and dating the form. Unsigned forms will be returned, so ensure your signature is legible and accurate.
8. After filling out the checklist, make a copy of the entire document for your records before sending it. You can then save changes, download, print, or share the completed form as necessary.

Complete your State-based Background Check Checklist online today to ensure a smooth application process.