DCYF CENTRAL REGISTRY NAME SEARCH AUTHORIZATION

I hereby request the NH Department of Health and Human Services (NH DHHS) to conduct a name search to determine if I am listed on the Department's Central Registry of founded reports of child abuse and neglect. My full legal name, other names I have used in the past, and other identifying information are listed below.

current full legal name (please print legibly):
other names i have used, including maiden name (if applicable):
date of birth	telephone number
month day year
current mailing address

I acknowledge that NH RSA 169-C:35 states it shall be unlawful for any employer to require my name to be reviewed against the Central Registry as a condition of employment unless specified in NH RSA 170-E or 170-G:8-c.

Signature: ______________________________________________	Date: ________________________

State of ________________________________________, County of ________________________________________, ss.

On this the ________ day of _____________, 20 ____, before me, __________________________, the undersigned officer,

(name of notary)

personally appeared ______________________________, known to me (or satisfactorily proven) to be the person described

(name of person)

above, and acknowledged this instrument.

Signature of notarial officer: ___________________________________	My commission expires on: _____________

In witness whereof I hereunto set my official seal.

Mail form and a self-addressed stamped envelope to: Division for Children, Youth and Families DCYF Central Registry, Thayer Building 129 Pleasant Street Concord, NH 03301	For Official Use only