DEPARTMENT OF CHILDREN AND FAMILIES FLORIDA ABUSE HOTLINE INFORMATION SYSTEM BACKGROUND CHECK Agency/Facility: Administrative Office of the Courts Pinellas Circuit Court 501 1st Avenue North Room 637 St. Petersburg, Florida 33701 Phone: (727) 582-7243 Fax: (727) 582-7406 _______________________________________________ To Be Completed by the Applicant: PLEASE SIGN LEGIBLY. All information must be completed or form will be returned. I (we) hereby give consent for the Department of Children and Families to conduct a search for confirmed reports of abuse, neglect, or exploitation on record concerning me. Type of Guardian (check one): Professional Family/Non Professional Employee X______________________________________________________(____)_________________ Applicant's Signature Date Current Phone Number Ward Name Date of Birth Social Security # Case number relationship to ward _____________________________________________________________________________ Guardian Please print Last Name First Full Middle Maiden/Prior Last Name Applicant: 1. _______________________________________________/ ____________ ___ ___ ____________ ______________________ Race Sex Date of Birth Social Security Number Other known names: ____________________________________________________ None Applicant: 2. Last Name First Full Middle Maiden/Prior Last Names ________________________________________/ ______________________ ____ ___ _____________ ________________________ Race Sex Date of Birth Social Security Number Other known names: ____________________________________________________ None List all residences within the state of Florida from 1978 until present. In the event of multiple occupancy within one county, list address of longest occupancy. Attach sheet for additional addresses if necessary. ________________________________________________________________________________ Applicant's Present Address Street City Zip County Dates of Residence ________________________________________________________________________________ Applicant's Previous Address Street City Zip County Dates of Residence We agree to keep confidential all information received as a result of background checks conducted, as required by Florida Statutes. We understand that release of this information to unauthorized persons is prohibited by law. American LegalNet, Inc. www.FormsWorkFlow.com