DCF CPS Check Form

Connecticut Department of Children and Families
AUTHORIZATION FOR DCF CPS BACKGROUND CHECK (Central Registry Only)
DCF-3031 Set
7/2022 (Rev.) 
Page 1 of 1
|, (Applicant Name): do hereby authorize the Department of Children and Families to research its
records and if applicable request out of state checks, to determine whether or not | am on the central registry of persons responsible for child abuse and neglect. |
understand that this information may be used to determine my suitability for (check one):
Employment [] Day Care L] Volunteer [intern [] Mentor CJ Other
I release the Department of Children and Families from any liability for any damages | may incur because of the release/use of this information.
Name of Agency (requesting background check) Attention:
Town of Waterford Christine Walters, HR Director
Address: (No. and Street): City: State: Zip:
15 Rope Ferry Road Waterford CT 06385
I submit the following information to assist the Department of Children and Families in their search.
Applicant Last Name: Applicant First Name: Middle: DOB:
Applicant Address: (No. and Street): Apt. # City: State: Zip: Start date at current
address: (mm/dd/yyyy)
List all previous applicant addresses for the last five years (1 Check if an additional sheet is necessary, and attached
Address (No. and Street): Apt. # City: State: Zip: Dates From:
To
(mmiddtyyyy) (mmiddiyyyy)
Other names | have used (including preferred names, maiden, and previous marriages) — [_] Check if an additional sheet is necessary, and attached
Last Name: First Name: Middle Name:
Names of ALL children - biological/step (Including adult children in or out ofthe home) [] Check if an additional sheet is necessary, and attached
Last Name: First Name: Middle: DOB: Gender:
(Female [JMale [Other
(Female [JMale [Other
(Female []Male [Other
This authorization will expire 180 days after the date of the signature
Applicant Signature: Date:
Submit at https://portal.dcf.ct.gov/Portal/Main/#dashboard. To enroll your agency in the portal, please contact
bgc.verification@ct.gov.
For questions or support, please contact the Background Check Unit at bgc.verification@ct.gov.