Michigan Department of Health and Human Services
(Revised 5-23)
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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
Format: (000) 000-0000.
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
Should be Empty: