OPWDD Form 159: Statewide Central Register Database Check Form

OPWDD Form 159
OPWDD Registered Provider Request for
STATEWIDE CENTRAL REGISTER DATABASE CHECK

OPWDD Form 159 Instructions
APPLICANT
LAST NAME*
FIRST NAME*
SEX M/F*
DATE OF BIRTH*

MonthDayYear
Date
MAIDEN/ALIAS
Any maiden names, previous married names, or aliases by which the applicant is or has been known
CELL-PHONE NUMBER*
Please enter a valid phone number.
E-MAIL*
example@example.com
HOUSEHOLD MEMBER AREA

ALL HOUSEHOLD MEMBERS, ADULTS AND CHILDREN, WHETHER RELATED TO THE APPLICANT OR NOT, ARE TO BE LISTED IN THIS AREA OF THE FORM.
If there are no other household members, indicate NONE in first "relationship" input box
- First column: Indicate the relationship to the applicant of each person listed. (Spouse, son, daughter, mother, father, friend, etc.)
- Sex M/F column: Fill in either M (Male) or F (Female) for every person listed.
- Date of Birth column: Fill in complete date of birth (mm/dd/yy) for everyone listed on the form.

HOUSEHOLD MEMBERS

	RELATIONSHIP	LAST NAME	FIRST NAME	SEX M/F	BIRTH MONTH	BIRTH DAY	BIRTH YEAR
HOUSEHOLD MEMBER. 1
HOUSEHOLD MEMBER. 2
HOUSEHOLD MEMBER. 3
HOUSEHOLD MEMBER. 4
HOUSEHOLD MEMBER. 5
HOUSEHOLD MEMBER. 6

ADDRESS AREA
- Provide addresses for the applicant. This information must be provided for the last 28 years.
- Complete addresses are required. Include street name and city/town/village, zip code. Also include street number and apartment number. Post Office
  Box numbers are not acceptable. If the applicant has lived abroad, indicate country and dates of residence. If the applicant has spent time in the
  military, list base names and locations along with dates. Be sure that there are no periods of time unaccounted for.
CURRENT STREET ADDRESS*
APT #
CITY*
STATE*
ZIP*
FROM*

MonthDayYear
Date
TO*

MonthDayYear
Date
PREVIOUS ADDRESS ( 1 )
APT #
CITY
STATE
ZIP
FROM

MonthDayYear
Date
TO

MonthDayYear
Date
PREVIOUS ADDRESS ( 2 )
APT #
CITY
STATE
ZIP
FROM

MonthDayYear
Date
TO

MonthDayYear
Date
PREVIOUS ADDRESS ( 3 )
APT #
CITY
STATE
ZIP
FROM

MonthDayYear
Date
TO

MonthDayYear
Date
I affirm that all the information provided on this form is true to the best of my knowledge. I understand that if I knowingly give false statements, such action could be grounds for denial or dismissal from employment or denial or revocation of a license, certificate, permit, registration or approval.
APPLICANT'S SIGNATURE*

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DATE*

MonthDayYear
Date
I authorize the New York Statewide Central Register of Child Abuse and Maltreatment (SCR) and the Office for People with Developmental Disabilities to furnish all information which may be contained within the SCR to the above named registered provider. If there is an indicated report as a result of the SCR check, I authorize the above named registered provider to contact the appropriate investigating entity to receive further information with regard to the incident indicated in the report.
APPLICANT'S SIGNATURE*

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DATE*

MonthDayYear
Date
Should be Empty:

APPLICANT

HOUSEHOLD MEMBER AREA

ADDRESS AREA