ࡱ> kmj'` FLbjbj{P{P 7V:: F& & & & & & & : 8LB: m8,zdddd?N4t.2 777777$9h<7]& !??!!7& & dd'8%%%!X& d& dt.%!t.%%:*,& & *d !XB* p+=80m8L*R<P"t<*<& *vST%D77$Xm8!!!!: : : : : : : : : & & & & & &  EMPLOYER OR VOLUNTEER AGENCY CENTRAL REGISTRY CLEARANCEINSTRUCTIONS:All fields must be typed and completed for processing. Attach a copy of your agency badge OR fax cover that includes agency letterhead Attach a copy of each individuals picture identification.SECTION 1 Employee/Volunteer Information (Attach additional sheets if more rows are needed)NAME (INCLUDING ALSO KNOWN AS NAMES, INCLUDNG MAIDEN NAMES)DATE OF BIRTHSOCIAL SECURITY NUMBER (IF KNOWN)Phone #SIGNATURE OF EMPLOYEE/VOLUNTEER FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      SECTION 2 Inquiring Employer/Volunteer Agency Name, Address, Phone and Fax NumberRequesting Staff Name & Title FORMTEXT      Employer/Volunteer Agency Name FORMTEXT      Employer/Volunteer Agency Address FORMTEXT      Office Phone FORMTEXT      Office Fax FORMTEXT      SECTION 3 Sign, Date, and Mail or Fax this Form to the Address BelowIn-state requests: Contact the local DHS office.Out-of-state requests: Michigan Department of Human Services Childrens Protective Services P.O. Box 30037 235 S. Grand Avenue, Suite 510 Lansing, MI 48909-8150 Phone: 517-335-3704 Fax: 517-241-7047The confidentiality of central registry information is protected by Sections 7 through 7j the Michigan Child Protection Law (MCL 722.627-722.627j). 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FORMTEXT       FORMTEXT      SignatureDateNameDepartment of Human Services (DHS) will not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, sex, sexual orientation, gender identity or expression, political beliefs or disability. If you need help with reading, writing, hearing, etc., under the Americans with Disabilities Act, you are invited to make your needs known to a DHS office in your area.     DHS-640 (Rev. 01-10) Previous edition obsolete. 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