Supplemental Application for positions with children

Personal Information Sheet

Supplemental Application

Education

Professional License or Certification

Employment History

Personal References

Supplemental Application

Signatures and Authorization for Release of Information

Personnel Information

To prevent the delay of Background investigations.

Applications must be filled out completely.

List current working phone numbers.

List employment from the past five (5) years. Attach all certified transcripts/diploma's.

Please provide copy of CDIB (if applicable).

DO NOT USE RELATIVES FOR PERSONAL REFERENCES.
Personal Information Sheet

Background Investigation
Name

First NameMiddle NameLast Name
Aliases Name

First NameMiddle NameLast Name
From

MonthDayYear
Date
Till

MonthDayYear
Date
Aliases Name

First NameMiddle NameLast Name
From

MonthDayYear
Date
Till

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Enrolled Tribal Member?

YesNo
Enrolled Member of Another Tribe?

YesNo
Enrollment Number: 2801 A
Name of Tribe & Enrollment Number
Social Security Number
xxx-xx-xxxx
Driver's License:

YesNo
State Issued:
Driver's License Number
Driver's License Type
Height (inches)
Weight
Hair Color
Eye Color
Date of Birth

MonthDayYear
Date
Place of Birth

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
List all States you have lived in for the past five (5) years:
List all Countries you have lived in the past thirty (30) years:

Supplemental Application

Part 1
Where You Have Lived: (List addresses for the past 5 years.)
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
From

MonthDayYear
Date
Till

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
From

MonthDayYear
Date
Till

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
From

MonthDayYear
Date
Till

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
From

MonthDayYear
Date
Till

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
From

MonthDayYear
Date
Till

MonthDayYear
Date

Personal References

Do not list your spouse, former spouse, relatives or persons appearing elsewhere on this form
Name
Phone Number

Area CodePhone Number
From month / year
To month / year
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name
Phone Number

Area CodePhone Number
From month / year
To month / year
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name
Phone Number

Area CodePhone Number
From month / year
To month / year
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name
Phone Number

Area CodePhone Number
From month / year
To month / year
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name
Phone Number

Area CodePhone Number
From month / year
To month / year
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Signatures and Authorization for Release of Information

Please read the following carefully and thoroughly
I understand that in applying for a position involving regular contact with or control over Indian
children or any child care services position, I must undergo a background check as mandated by
the Indian Child Protection and Family Violence Prevention Act, Pub. L. 101-630, 25 U.S.C.
‘3207, and the Crime Control Act of 1990, Pub. Law 101-647,42 U.S.C. ‘13041. Child care
services positions include, but are not limited to child protective services, social services, health
and mental health care, child/day care, education whether or not directly involved in teaching,
foster care, residential care, recreational or rehabilitative programs, and detention correctional or
treatment services.

I certify that all the information on this form and any attached sheets is true, correct complete
and made in good faith. I understand that false or fraudulent answer to any question may be
grounds for not hiring me, or for firing me after I begin work. I understand that any information I
give may be investigated for purposes of determining my fitness to have responsibility for the
safety and well-being of children and suitability to occupy a position involving regular contact
with or control over Indian children. I consent to the release of information about my ability,
fitness and suitability for employment with the Cheyenne and Arapaho Tribes by employers,
schools, law enforcement agencies, and other individuals and organizations to investigators,
personnel, specialist, and other authorized employees of the Cheyenne and Arapaho Tribes. I
understand that financial or lending institutions, medical institutions, hospitals, health care
professionals, or some other sources of information, may require the separate Authorization for
Release of Information I have signed. I also understand that I may challenge the accuracy and
completeness of any information obtained during the investigation of my background.

Public Law 101-647 requires that the application state that it is signed under penalty of perjury,
with the applicable Federal punishment for perjury.
Signature
Date

MonthDayYear
Date

Personnel Information
Program Name
Personnel or Applicant
Name

First NameMiddle NameLast Name
Social Security Number
Date of Birth

MonthDayYear
Date
All previous names, including aliases and maiden
Street Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number

Area CodePhone Number
Alternate Phone Number

Area CodePhone Number
Education
Do you have a high school diploma, General Education Development (GED) credential, or Licensing approved equivalent?

YesNo
When NO, are you in the process of obtaining a high school diploma, GED, or Licensing equivalent?

YesNo
What is the highest grade completed:
Configurable list*
College
College/university/school
Location(s)
Degree or credential
Major/Minor
Attendance (MM/YY-MM/YY)
Name during attendance

First NameLast Name
Graduation Date

MonthDayYear
Date
Number of completed semester hours if you did not graduate
College/university/school
Location(s)
Degree or credential
Major/Minor
Attendance (MM/YY-MM/YY)
Graduation Date

MonthDayYear
Date
Number of completed semester hours if you did not graduate

Previous Child Care Employment

Personal References
Name
Phone Number

Area CodePhone Number
Relationship
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name
Phone Number

Area CodePhone Number
Relationship
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name
Phone Number

Area CodePhone Number
Relationship
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Employer name

Full or Part-time