Arkansas DHS Criminal Background Check Request Form

Request for Criminal Background Check

Applicants should complete this form to request a Criminal Background Check consent form. Once you have completed the form, click “Submit Form” and you will receive an email to digitally sign the request. Please use the “Facility Email” field to provide the email address of either the Child Care facility or the Placement & Residential facility you are applying with.

Note: Please make sure to type in the correct email address or you will not be able to digitally sign your form.

Reason for Background Check*

Child Care Facility/Provider Name*

Facility License Number*

Placement/Residential Agency Name*

Facility Email*

Legal Name*

First Name

Middle Name (optional)

Last Name

Applicant Email*

Maiden Name

Aliases

Date of Birth*

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

SSN*

Phone Number*

Age*

Race*

Sex*

State of Birth*

Citizenship*

Height*

Weight*

Hair Color*

Eye Color*

Have you ever been convicted of a crime?*

Yes No

Please provide a description of the crime and specifics of the conviction.

Drivers License Number*

State DL Issued In*