Michigan Department of Health and Human Services
(Revised 5-23)
SECTION 1 - INFORMATION ON PERSON BEING CLEARED
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Name
First Name
Last Name
Social Security Number
Maiden Name Aliases also known as AKA
Date of Birth
/
Month
/
Day
Year
Date
Address
Address
Street Address Line 2
City
State
Zip Code
Phone Number
Email
example@example.com
County (For Michigan Residents Only)
Signature Required for Individual Being Cleared
Date
/
Month
/
Day
Year
Date
Requester Information
Volunteer Agency
Name of Agency or Organization
Name of Requester
Requester Address
Requester City
Requester State
Requester Zip Code
Requester Email
Fax
Requester Phone Number
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