Fill a Valid Georgia 5579 Template
Article Structure
Common mistakes
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Neglecting to Print Clearly: Many applicants fail to print their information legibly. This can lead to misunderstandings or errors in processing the application. Use a ballpoint pen and press firmly to ensure clarity.
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Incorrectly Checking Applicant Type: Some individuals mistakenly check more than one box for the applicant type. It's important to accurately indicate whether you are a Director/Manager, Owner, or Employee with a criminal history.
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Omitting Required Information: Applicants sometimes forget to include critical details, such as their maiden name, Social Security Number, or place of birth. Ensure that all requested information is filled out completely.
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Failing to Notarize the Application: All applications must be notarized. Without a notary's signature, the application will be considered incomplete and may be rejected.
Essential Points on This Form
What is the purpose of the Georgia 5579 form?
The Georgia 5579 form is a Residential Child Care Records Check Application. It is used to authorize the Department of Human Resources to conduct a criminal history background check on individuals who are applying to work in or manage a residential child care facility. This form ensures that potential employees or owners meet the necessary legal requirements to provide care for children in such facilities.
Who needs to complete the Georgia 5579 form?
What information is required on the form?
Is notarization required for the Georgia 5579 form?
What happens after submitting the Georgia 5579 form?
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Georgia 5579 Sample
Georgia Department of Human Resources
RESIDENTIAL CHILD CARE
RECORDS CHECK APPLICATION (See Instructions on Back of Form)
TO BE COMPLETED BY APPLICANT:
1. CHECK APPLICANT TYPE: |
Director/Manager |
Owner
Employee (with criminal history)
2.Print Name ____________________________________________________________________________
|
(Last) |
(First) |
(Middle) |
(Maiden) |
(Date of Birth) |
|
________ |
______ |
__________________________ |
________________________ |
|||
(Sex) |
(Race) |
(Social Security Number) |
|
|
(Place of Birth) |
|
_________ __________ ______________ _____________ __________________________
(Height) (Weight) (Color of Eyes) (Color of Hair) (Home Telephone)
__________________________________________________________________________________
(Mailing Address) |
(City) |
(State) |
(Zip) |
3.I hereby authorize the Department of Human Resources and my potential employer named below to receive any criminal history record information pertaining to me which may be in the files of any state or local criminal justice agency in Georgia. As required by Law, I have attached an affidavit disclosing the nature and date of any arrest, charge, or conviction, for the violation of any law in any state, except for motor vehicle parking violations.
___________________________________ |
_____________________________________ |
(Notary) |
(Applicant Signature) |
Notary Public ________________, Georgia |
My Commission Expires: _________________ |
(County) |
(Date) |
TO BE COMPLETED BY OWNER/DIRECTOR OF RESIDENTIAL CHILD CARE FACILITY OR APPLICANT FOR LICENSE:
(PLEASE PRINT CLEARLY)
4. _______________________________________________________________________________________
(PRINT Name of Residential Child Care Facility) (PRINT RCC Address) (PRINT City/Zip Code of PCH)
_______________________________________________________________________________________
(PRINT mailing address, if different from RCC address) |
(PRINT City/Zip Code/County Name) |
5.THE RESIDENTIAL CHILD CARE FACILITY IDENTIFIED ABOVE: (CHECK ONE)
Is currently licensed.
Is applying for an initial (new) license at the above address.
6.My signature indicates that I, as DIRECTOR/OWNER, have verified the above information on the above applicant.
________________________________________ |
____________________________________________ |
(PRINT Name of Director/Owner) |
(Telephone of Agency) |
_______________________________________ |
____________________________________________ |
(Signature of Director/Owner) |
(Date) |
Form 5579 (Rev.4/18/08) YOU MAY DUPLICATE AND KEEP FOR YOUR RECORDS
Application Instructions
Do not have the Live Scan done before turning in your application package.
1.Please use a ball point pen, press firmly, and PRINT legibly.
2.Please indicate if you are a director/ manager, an owner or an employee (with a criminal history). You should check both owner and director/manager if you are both the administrator and the owner.
3.Print your full name, including your MAIDEN name. DO NOT use initials if your have a given name.
Print your date of birth. Print either: Male or Female.
Print your race: Black, White, or Other. Print your Social Security Number.
Print your place of birth: City or County, State and Country if not USA. Print your height.
Print your weight.
Print the color of your eyes: Do NOT abbreviate: Brown, Black, Grey, Blue, Green, or Hazel.
Print the color of your hair: DO NOT abbreviate: Brown, Black, Grey, Red, Blonde, or Bald. Print your home address.
Print your home telephone number.
4.ALL APPLICATIONS MUST BE NOTARIZED. Read the consent statement.
Sign your name as you would on a bank check or business letter.
DIRECTOR/OWNER WILL COMPLETE THE FOLLOWING
5.Record check results will be mailed to the address that is entered here. Print clearly and give complete mailing address.
Indicate name of your facility as it appears on your permit or permit application. Print the address of the Residential Child Care Facility.
Print the mailing address where the letter of determination is to be sent. Print the city/zip/county.
6.Check the correct box to indicate current licensure status for your Residential Child Care facility.
7.Director or Owner must sign his/her name as it would appear on a bank check or business letter.
8.This form must be completed and brought with you for Live Scans at 2 Peachtree or specified
Office of Investigative Services
Background Investigations Unit
2 Peachtree Street, N.W., Suite 30.482
Atlanta, GA.
9.If the Criminal Records Check Application is not received by OIS, you will not receive a determination letter.
10.This form should be sent to OIS before the fingerprinting at the COGENT/GAPS location is done.
Key takeaways
Filling out the Georgia 5579 form is a crucial step in the process of obtaining a Residential Child Care Records Check. Here are some key takeaways to keep in mind:
- Complete All Sections: Ensure that every section of the form is filled out completely. This includes personal information such as your full name, date of birth, and social security number. Incomplete forms can lead to delays.
- Authorization is Essential: By signing the form, you authorize the Department of Human Resources and your potential employer to access your criminal history. Be aware that this is a necessary step for your application to proceed.
- Notarization Required: All applications must be notarized. Make sure to sign the form in the presence of a notary public to validate your application.
- Correct Licensure Status: Indicate whether your Residential Child Care facility is currently licensed or applying for a new license. This information is crucial for processing your application correctly.
- Submit Before Fingerprinting: Remember to submit the completed form to the Office of Investigative Services before undergoing fingerprinting at the designated locations. Failure to do so may result in not receiving a determination letter.
By following these guidelines, you can help ensure a smoother application process for your Residential Child Care Records Check.
Document Characteristics
| Fact Name | Details |
|---|---|
| Form Title | Residential Child Care Records Check Application |
| Governing Law | Georgia Code § 49-5-12.1 |
| Applicant Types | Includes Director/Manager, Owner, and Employee (with criminal history). |
| Authorization Requirement | Applicants must authorize the Department of Human Resources to access their criminal history records. |
| Notarization | All applications must be notarized for validity. |
| Information Required | Personal details such as name, date of birth, social security number, and physical characteristics must be provided. |
| Licensure Status | Applicants must indicate whether the facility is currently licensed or applying for a new license. |
| Mailing Address | Record check results will be mailed to the address provided on the form. |
| Submission Instructions | The form must be submitted before fingerprinting at designated locations. |