This form contains 68 fields organized into 27 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name	Type	Description
Agency Information
Agency Name	Text	Please provide the full legal name of the agency.
Agency Mailing Address	Text	Please provide the street location for the agency's mailing address.
Agency City, State, Zip	Text	Please provide the city, state, and zip code for the agency's mailing address.
Agency Phone Area Code	Text	Please provide the three-digit area code for the agency's phone number. Max length: 3 characters
Agency Phone Number	Text	Please provide the seven-digit main phone number for the agency, excluding the area code.
Applicant Identification
CYCIS Case Manager ID	Text	Provide the CYCIS Case Manager ID, if applicable.
Social Security Number	Text	Enter the applicant's Social Security Number.
Date of Birth	Date	Enter the applicant's date of birth.
Full Name	Text	Enter the applicant's full legal name, including last, first, and middle names.
Maiden or AKA Name	Text	Enter the applicant's maiden name or any other 'also known as' name.
CFS 718-B Completion Status
CFS 718-B Completed	Checkbox	Check this box if you are a new POS employee and have completed the CFS 718-B with your employer. Fill only if 'I WORK FOR' is 'POS AGENCY'. Depends on: POS AGENCY
CFS 718-B Not Completed	Checkbox	Check this box if you are a new POS employee and have not completed the CFS 718-B with your employer. Fill only if 'I WORK FOR' is 'POS AGENCY'. Depends on: POS AGENCY
Child Abuse/Neglect Investigation Question
Child Abuse/Neglect Investigation - Yes	Checkbox	Check this box if you are currently the subject of a child abuse or neglect investigation. Fill only if 'Notification of Change' is 'No'. Depends on: Notification of Change
Child Abuse/Neglect Investigation - No	Checkbox	Check this box if you are not currently the subject of a child abuse or neglect investigation. Fill only if 'Notification of Change' is 'No'. Depends on: Notification of Change
Child Abuse/Neglect Report History Question
Yes	Checkbox	Check this box if you have ever been the perpetrator of an indicated child abuse or neglect report. Fill only if 'Notification of Change' is 'No'. Depends on: Notification of Change
No	Checkbox	Check this box if you have never been the perpetrator of an indicated child abuse or neglect report. Fill only if 'Notification of Change' is 'No'. Depends on: Notification of Change
DCFS Region
Northern	Checkbox	Check this box if your DCFS region is Northern. Fill only if 'DCFS' is 'Yes'. Depends on: DCFS
Cook North	Checkbox	Check this box if your DCFS region is Cook North. Fill only if 'DCFS' is 'Yes'. Depends on: DCFS
Central	Checkbox	Check this box if your DCFS region is Central. Fill only if 'DCFS' is 'Yes'. Depends on: DCFS
Cook Central	Checkbox	Check this box if your DCFS region is Cook Central. Fill only if 'DCFS' is 'Yes'. Depends on: DCFS
Southern	Checkbox	Check this box if your DCFS region is Southern. Fill only if 'DCFS' is 'Yes'. Depends on: DCFS
Cook South	Checkbox	Check this box if your DCFS region is Cook South. Fill only if 'DCFS' is 'Yes'. Depends on: DCFS
Driver's License Information
Driver's License Number	Text	Please provide the driver's license number.
Issuing State	Text	Please provide the state that issued the driver's license.
Expiration Date	Date	Please provide the expiration date of the driver's license.
Education Information
College Attended	Text	Please enter the name of the college you attended.
Degree	Text	Please enter the degree you obtained or are pursuing.
Year Completed	Text	Please enter the year you completed your degree.
Educational Loan Question
YES	Checkbox	Check this box if you are currently in default of an educational loan. Fill only if 'Notification of Change' is 'No'. Depends on: Notification of Change
NO	Checkbox	Check this box if you are not currently in default of an educational loan. Fill only if 'Notification of Change' is 'No'. Depends on: Notification of Change
Email
Email	Text	Please provide your email address.
Executive Director Information
Executive Director's Name	Text	Please provide the full name of the Executive Director.
Executive Director's Phone	Text	Please provide the phone number of the Executive Director.
Fingerprinted Recently Status
Yes	Checkbox	Check this box if you have been fingerprinted recently.
No	Checkbox	Check this box if you have not been fingerprinted recently.
First Professional License/Certification
License Type	Text	Please provide the type of the professional license or certification you have held. Fill only if 'Notification of Change' is 'No'. Depends on: Notification of Change
License Number	Text	Please enter the license or certificate number for the professional license or certification you have held. Fill only if 'Notification of Change' is 'No'. Depends on: Notification of Change
Home Address
Street Address	Text	Please enter your home street address.
City, State, and Zip Code	Text	Please provide your home city, state, and zip code.
County	Text	Please enter the county of your home address.
Home Phone
Home Phone Area Code	Text	Provide the three-digit area code for your home phone number. Max length: 3 characters
Home Phone Local Number	Text	Provide the seven-digit local number for your home phone.
License Disciplinary Action Question
YES	Checkbox	Check this box if any of your licenses have ever been denied, suspended, revoked, or subjected to disciplinary action by any jurisdiction. Fill only if 'Notification of Change' is 'No'. Depends on: Notification of Change
NO	Checkbox	Check this box if none of your licenses have ever been denied, suspended, revoked, or subjected to disciplinary action by any jurisdiction. Fill only if 'Notification of Change' is 'No'. Depends on: Notification of Change
Notification of Change
Notification of Change	Checkbox	Check this box if this submission is solely for notifying a change of agency, name, or address.
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YES	Checkbox	Check this box if you have ever been convicted of or have a pending charge for any of the offenses listed under the Criminal Code of 1961 as specified in the Child Care Act of 1969. Fill only if 'CHECK HERE IF this is only notification of CHANGE of agency, name, or address.' is 'No'. Depends on: Notification of Change
NO	Checkbox	Check this box if you have never been convicted of and do not have a pending charge for any of the offenses listed under the Criminal Code of 1961 as specified in the Child Care Act of 1969. Fill only if 'CHECK HERE IF this is only notification of CHANGE of agency, name, or address.' is 'No'. Depends on: Notification of Change
Perjury/Falsification Conviction Question
YES	Checkbox	Check this box if you have ever been convicted of perjury or falsification of anything in a case file. Fill only if 'Notification of Change' is 'No'. Depends on: Notification of Change
NO	Checkbox	Check this box if you have never been convicted of perjury or falsification of anything in a case file. Fill only if 'Notification of Change' is 'No'. Depends on: Notification of Change
Re-instatement Justification
Reinstatement Justification	Text	Please provide the specific reasons for your request to reinstate your license. Fill only if 'Notification of Change' is 'No'. Depends on: Notification of Change
Required Explanations Attached Status
Yes	Checkbox	Check this box if you have attached all required explanations. Fill only if 'Have you ever been convicted of or have a pending charge for any offenses listed' is 'YES'. Depends on: YES
No	Checkbox	Check this box if you have not attached all required explanations. Fill only if 'Have you ever been convicted of or have a pending charge for any offenses listed' is 'YES'. Depends on: YES
Second Professional License/Certification
Second Professional License Type	Text	Enter the type of the second professional license or certification held. Fill only if 'Notification of Change' is 'No'. Depends on: Notification of Change
Second Professional License Number	Text	Provide the license or certificate number for the second professional license or certification held. Fill only if 'Notification of Change' is 'No'. Depends on: Notification of Change
Supervisor Information
Supervisor Email	Text	Provide the email address of the supervisor.
Supervisor Name	Text	Enter the full name of the supervisor.
Supervisor Phone Area Code	Text	Provide the three-digit area code for the supervisor's phone number. Max length: 3 characters
Supervisor Phone Main Number	Text	Enter the seven-digit main part of the supervisor's phone number.
Supervisor Phone Extension	Text	If applicable, provide the extension for the supervisor's phone number.
Transcript Request Status
Yes	Checkbox	Check this box if you have requested your transcript from college showing your degree.
No	Checkbox	Check this box if you have not requested your transcript from college showing your degree.
Valid Driver's License Copy Attached Status
Yes	Checkbox	Check this box if you have attached a copy of your valid driver's license. Fill only if 'Do you have a valid state issued driver's license?' is 'YES'. Depends on: YES
No	Checkbox	Check this box if you have not attached a copy of your valid driver's license. Fill only if 'Do you have a valid state issued driver's license?' is 'YES'. Depends on: YES
Valid Driver's License Question
YES	Checkbox	Check this box if you have a valid state-issued driver's license. Fill only if 'Notification of Change' is 'No'. Depends on: Notification of Change
NO	Checkbox	Check this box if you do not have a valid state-issued driver's license. Fill only if 'Notification of Change' is 'No'. Depends on: Notification of Change
Work Affiliation
DCFS	Checkbox	Check this box if you work for the Department of Children and Family Services (DCFS).
POS AGENCY	Checkbox	Check this box if you work for a Purchase of Service (POS) agency.
Other	Checkbox	Check this box if your work affiliation is neither DCFS nor a POS agency.

CFS 718, Application for Child Welfare Employee Licensure Instructions