Form CANTS 22, Authorization for Background Check for Programs Not Licensed by DCFS Instructions

Please enter your current age.

Please enter the three-digit area code of the cell phone number.

Please enter the three-digit prefix of the cell phone number.

Please enter the four-digit line number of the cell phone number.

Check this box if you have ever been indicated as a perpetrator in a child abuse or neglect investigation.

Check this box if you have never been indicated as a perpetrator in a child abuse or neglect investigation.

Check this box if your citizenship is USA.

Check this box if your citizenship is other than USA and you need to specify it.

Please specify the country of your citizenship if it is not USA. Fill only if 'Other Specify' is 'Yes'.

Enter the full legal name of the contractor.

Enter the unique identification number assigned to the contractor as a provider.

Enter the street number and name of the contractor's primary address.

Enter the city of the contractor's primary address.

Enter the five-digit or nine-digit ZIP code for the Illinois address.

Enter the county of the contractor's primary address.

Check this box if you have ever been convicted of a criminal offense, other than a minor traffic violation.

Check this box if you have never been convicted of a criminal offense, other than a minor traffic violation.

Please provide your current street address and, if applicable, your apartment or unit number.

Please enter the current city where you reside.

Please enter the two-letter abbreviation for the current state where you reside.

Please enter the current postal zip code for your address.

Please enter the current county where you reside.

Please enter the month of birth (MM).

Please enter the day of birth (DD).

Please enter the year of birth (YYYY).

Enter the numerical code corresponding to your ethnicity as provided on Page 2.

Provide the street number, apartment number, city, county, state, and zip code for the fifth previous address. Fill only if 'Yes' is 'Yes'.

Provide the start and end dates for residing at the fifth previous address. Fill only if 'Yes' is 'Yes'.

Provide the full street address, apartment number, city, county, state, and zip code for the first previous address lived at within the last five years. Fill only if 'Yes' is 'Yes'.

Provide the start and end dates for when you resided at the first previous address, in a 'From/To' format. Fill only if 'Yes' is 'Yes'.

Please enter the street, apartment number, city, county, state, and zip code for the fourth previous address. Fill only if 'Yes' is 'Yes'.

Please provide the start and end dates for the fourth previous address. Fill only if 'Yes' is 'Yes'.

Check this box if the individual identifies as male.

Check this box if the individual identifies as female.

Please provide the last name of the individual.

Please provide the first name of the individual.

Please provide the middle initial of the individual.

Please provide the unique identification number assigned to the provider.

Please enter the three-digit area code for your home telephone number.

Please enter the three-digit prefix for your home telephone number.

Please enter the four-digit line number for your home telephone number.

Provide the first maiden name or any other name formerly used, including last name, first name, and middle initial.

Provide a second maiden name or any other name formerly used, including last name, first name, and middle initial.

Please provide the full name of the contract liaison.

Please provide the full name of the contractor.

Please provide your last name.

Please provide your first name.

Please provide your middle initial.

Enter the three-digit area code for the contract liaison's phone number.

Enter the three-digit prefix of the contract liaison's phone number.

Enter the four-digit line number of the contract liaison's phone number.

Enter the applicant's height in feet.

Enter the applicant's weight in pounds.

Enter the applicant's hair color.

Enter the applicant's eye color.

Provide the city and state where the individual was born.

Check this box if you have lived outside of Illinois in the past 5 years.

Check this box if you have not lived outside of Illinois in the past 5 years.

Enter the last name of the person whose name is being printed.

Enter the first name of the person whose name is being printed.

Enter the middle initial of the person whose name is being printed.

Please enter the printed Provider ID.

Please enter the Provider ID number.

Check this box if you identify as Native American/Alaskan (Indian or Eskimo).

Check this box if you identify as Asian.

Check this box if you identify as Black/African American.

Check this box if you identify as Native Hawaiian/Pacific Islander.

Check this box if you identify as White.

Check this box if your racial identity is unknown.

Check this box if you decline to identify your race.

Check this box if your racial identification could not be verified.

Please enter the complete street address, including apartment number, city, county, state, and zip code for the second previous address listed. Fill only if 'Yes' is 'Yes'.

Please provide the start and end dates for the second previous address. Fill only if 'Yes' is 'Yes'.

Enter the first three digits of your Social Security Number or ITIN.

Enter the remaining six digits of your Social Security Number or ITIN.

Please provide the street number, apartment number, city, county, state, and zip code for your third previous address. Fill only if 'Yes' is 'Yes'.

Please provide the start and end dates for your residency at the third previous address. Fill only if 'Yes' is 'Yes'.