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Get AK DHSS 06-9437 2011

Household Member Signature 06-9437 Rev. 12/2011 Date LIC ADOP CPS Page 1 of 4 Authority AS 47. 05. 310 AS 47. 32 42 U.S.C. 671 a 20 OCS/CPA Use Only Background Check Program Cleared Yes Worker Name No Date Child Protective Service Record Checks Yes Information Attached Criminal Justice History Yes Printout Attached Court Records Problem Sex Offender Registry History Previous Licensing Problem Comments Name of worker who did the checks Date Alaska.

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