CFS 689
Rev 7/2012
State of Illinois
Department of Children and Family Services
AUTHORIZATION FOR BACKGROUND CHECK
Child Abuse and Neglect Tracking System (CANTS)
For Programs NOT Licensed by DCFS
NOTE: Do not use this form if you are an applicant for licensure or an employee/volunteer of a licensed child
care facility. Please contact your licensing representative.
Name:
Last First Middle
Race:
Male Female
Gender:
Current Address:
Street/Apt #
City State Zip Code
If you currently reside in Illinois, please list all previous addresses for the past five years.
OR
If you currently reside out-of-state, please provide ALL Illinois addresses in which you did reside while living in Illinois.
Dates
(Street/Apt#/City/County/State/Zip Code) From/To
List maiden name and/or all other names by which you have been known: (last, first, middle)
I hereby authorize the Illinois Department of Children and Family Services to conduct a search of the Child Abuse and Neglect
Tracking system (CANTS) to determine whether I have been a perpetrator of an indicated incident of child abuse and/or neglect
or involved in a pending investigation. I further consent to the release of this information to the agency listed below.
Signed Date
Please type, use bold letters or label:
(Agency Name)
(Contact Person)
(Address)
(City/State/Zip)
FAX to: 217-782-3991
Scan/Email to: CFS689Background@illinois.gov
Submit by mail OR fax OR email.
Mail to:
Department of Children and Family Services
406 E. Monroe – Station # 30
Springfield, IL 62701
(Submitting Agency Fax Number)
(Submitting Email Address)
Date of Birth: -- --
