DHS Central Registry Clearance Request

DHS CENTRAL REGISTRY CLEARANCE REQUEST

Michigan Department of Health and Human Services
SECTION 1 INFORMATION ON PERSON BEING CLEARED
Name *
First, Middle, Last
Also Known as Name (AKA)
Maiden Name
Date of Birth*

MonthDayYear
Date
Social Security Number*
Address*

Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Email*
example@example.com
Please upload a SCANNED DOCUMENT (NOT A PHOTO) of your Driver's License*

We recommend the app CamScanner to help scan your ID. Please NO PHOTOS.
Cancelof
License Upload Example:

*A fake license was used for this example*

Correct:

Incorrect:
Click the a link below to download CamScanner if you need to scan your ID:

Apple Store:

https://apps.apple.com/us/app/camscanner-pdf-scanner-app/id1543833156?mt=12

Google Play Store:

https://play.google.com/store/apps/details?id=com.intsig.camscanner&pcampaignid=web_share

Once you scan your ID, you can save it to your photos or files app and then upload it to this form.
Today's Date*

MonthDayYear
Date
Signature Required for Individual Being Cleared*

Clear
Should be Empty:

DHS CENTRAL REGISTRY CLEARANCE REQUEST