ONLY FOR ARKANSAS DEPARTMENT OF EDUCATION USE
AUTHORIZATION FOR RELEASE OF CONFIDENTIAL INFORMATION
By the Arkansas Child Maltreatment Central Registry
Applicant Instructions: Complete this form, have it notarized, and submit a personal check, cashier's check OR a U.S. money order
for $10.00 made payable to the Arkansas Department of Human Services. DO NOT SEND CASH OR A TEMPORARY CHECK-
YOUR REQUEST WILL NOT BE PROCESSED. Make and keep a copy of this form for your records.
PLEASE allow four weeks before contacting the Arkansas Department of Education concerning completion of your report.
Mail this notarized form and the fee payment to: Arkansas Child Maltreatment Central Registry Applicant- Check Only One:
P.O. Box 1437, Slot S 566 Licensed Teacher
Little Rock, Arkansas 72203 Non-licensed/Classified
Applicant’s full name (print or type):
First Middle Last
List ALL other names used:
Applicant’s Social Security Number: - -
Applicant’s Birth Date (Month/Day/Year): _ Age: Race/ethnicity: Gender:
Applicant’s mailing address: _ Physical Address:
Street or P.O. Box Street
City State Zip Code City State Zip Code
Applicant’s phone number : (home) (cell) (email)
List the full name and date of birth (Month/Day/Year) for all of the applicant’s children, attach additional paper if necessary:
(Failure to list your children, may be considered fraud & result in the denial of application)
2.
Child’s Full Name:
3.
Child’s Full Name:
Child’s Date of Birth:
Child’s Date of Birth:
(Applicant) School District Contact Person
I hereby request that the Arkansas Child Maltreatment Central Registry release any information their files may contain indicating the
undersigned applicant as an offender of a true report of child maltreatment to the ARKANSAS DEPARTMENT OF EDUCATION.
By signing below, I swear or affirm that the foregoing statements are true to the best of my knowledge and belief under
penalty of perjury.
Applicant’s Signature:
State of County of
Date
On this the day of _, 20 , before me, (name of notary), the undersigned notary, personally
appeared (applicant’s name) known to me (or satisfactorily proven) to be the person whose name(s)
is/are subscribed to the within instrument and acknowledged that he/she/they executed the same for the purposes therein contained.
In witness whereof I hereunto set my hand and official seal.
Notary Public: My Commission Expires:
ADE Form Effective Date 06/06/2019
INCOMPLETE OR UNNOTARIZED FORMS WILL NOT BE PROCESSED BY THE CENTRAL REGISTRY OR THE ADE!
