Welcome to the New York Citizen Teacher Background Check Form!
Information collected in the following section will be used
to determine whether or not you are subject to an indicated report of child abuse and maltreatment. The background
check will be run by the New York State
Statewide Central Registry online database.
All the information you provide will be stored in a secure database.
Contact Information
If any of the auto-filled information below is inaccurate, please correct it here.
First Name
Middle Name
Last Name
Sex
Please select...
Female
Male
Date of Birth (MM/DD/YYYY)
Phone Number
Email Address
Current Address
Current City
Current State
Please select...
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
Not a US State
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
Current Zip Code
Do you have a maiden/alias? This includes each maiden name, previously married name and AKA (Also Known As).
Yes
No
First and Last Name
Do you have a US social security number?
Yes
No
Social Security or Alien Registration Number
This information will be used to determine if you
are listed on the register of substantiated category one cases of abuse or neglect maintained by the Justice Center for the Protection of Persons with Special Needs.
Page 2
Information collected in the following section will be used
to determine whether or not you are subject to an indicated report of child abuse and maltreatment. The background
check will be run by the New York State
Statewide Central Registry online database.
Household Members
Do you have anyone residing with you at
your current address
(listed on page 1 of this form)?
Yes
No, I live alone
Please list
all
individuals currently residing with you at
your current address
. (
Repeat until all household members are listed.
)
Relationship to you
Please select...
Spouse
Family Member
Other household member
Household Member First Name
Household Member Last Name
Household Member Date of Birth (MM/DD/YYYY)
Sex
Male
Female
Information collected in the following section will be used
to determine whether or not you are subject to an indicated report of child abuse and maltreatment. The background
check will be run by the New York State
Statewide Central Registry online database.
Your Addresses
Please provide all addresses in which you have resided
for the last 28 years
,
or since birth if you are under 28
. Please note that Post Office Boxes will not be accepted.
Work backwards from your current address.
Make sure all dates are consecutive (there should be no gaps in dates). For example, if you lived in your last address from 02/2005 to 02/2012, the address you list next should include 02/2005 as the date for "When did you stop living at the residence?"
Current Address
When did you start living at
your current
residence
(listed on the page 1 of this form)? Please use MM/YYYY format.
Previous Addresses
Is this a USA address?
Yes
No
What country?
Street Address
Apartment Number
City
State
Please select...
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
Zip Code
When did you start living at this residence?
(MM/YYYY)
When did you stop living at this residence? (
MM/YYYY)
Please provide three references, two of which must be employment references.
References may be contacted to verify your employment history, work record, personal and professional qualifications, character, and habits.
Personal Reference
Must know for a minimum 2 years, cannot be a relative.
Reference 1 First Name
Reference 1 Middle Initial
Reference 1 Last Name
Reference 1 Company Name
Reference 1 Street Address
Reference 1 Apartment Number
Reference 1 City
Reference 1 State
Please select...
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
Not a US State
Reference 1 Zip Code
Reference 1 Country
Reference 1 Daytime Phone Number
Reference 1 Email Address
Employment References
Must know for a minimum 1 year, cannot be a relative.
Reference 2 First Name
Reference 2 Middle Initial
Reference 2 Last Name
Reference 2 Company Name
Reference 2 Street Address
Reference 2 Apartment Number
Reference 2 City
Reference 2 State
Please select...
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
Not a US State
Reference 2 Zip Code
Reference 2 Country
Reference 2 Daytime Phone Number
Reference 2 Email Address
Reference 3 First Name
Reference 3 Middle Initial
Reference 3 Last Name
Reference 3 Company Name
Reference 3 Street Address
Reference 3 Apartment Number
Reference 3 City
Reference 3 State
Please select...
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
Not a US State
Reference 3 Zip Code
Reference 3 Country
Reference 3 Daytime Phone Number
Reference 3 Email Address
Please attach a copy of your resume. This meets the NY State Office of Children and Family Services background check requirement of a statement or summary of each applicant's employment history including, but not limited to, any relevant child-caring experience.
THANK YOU for completing this background check form!
Visit the clearance website to complete all remaining steps: medical, fingerprinting, and online training
.
A Citizen Schools staff member will contact you if we have any questions.
Contact Information