Criminal Background Check [Required]

Records Check Application for Employment
The following information is required by our vendor, COGENT, to process the national fingerprint-based records check for employees of the Bright from the Start: Georgia Department of Early Care and Leaming (DECAL) and vendor/contractor employees that may perform any work at a child care facility of behalf of DECAL in compliance with O.C.G.A.§ 20-1A-24(b). Please complete the worksheet below, the Cogent Applicant Processing Services Acknowledgement form and submit both forms with the CACFP application for participation.
Last Name*
First Name*
Middle Name*
Suffix
Date of Birth*

MonthDayYear
Date
Place of Birth*
City, St.
Social Security Number*
Gender*

MaleFemale
Race*
Eye Color*
Hair Color*
Weight *
Height*
Country of Citizenship*
Drivers License Number*
Drivers License State*
Address*
City*
State*
Zip Code*
Phone Number*
Signature*

Clear
Date*

MonthDayYear
Date
Do you receive any retirement income from the State of Georgia

YESNO
Name of Applicant printed*
I hereby authorize DECAL to receive any criminal history record information pertaining to me which may be on file with any criminal justice agency in the United States and its territories. I further authorize DECAL to release a fitness determination to the Department or Vendor employer. I understand that this authorization is valid for up to and including 180 days from the date of this signature. Georgia law authorizes DECAL to require additional fingerprint records checks when the department has reason to believe that I have a criminal record that renders me ineligible to have contact with children in a licensed child care facility or during the course of a child abuse investigation.
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Records Check Application for Employment