Out of State Registry Check (If you work for a child care in TN)

The overall background check process includes a check of any applicable out of state registries if the applicant has lived in another state during the last (5) years. Please see the instructions for completing the out of state registry check portion of the background check process below.

If an applicant for child care employment has lived in another state during the last five (5) years select the state(s) from the tabs at the top of the box with the corresponding first letter of the state for which you are searching and follow the instructions for each state in which the individual has lived. Submit the forms as instructed along with any required documentation. Each form may have different requirements. Most forms require a signature. Others may require a witness, original signatures, notarization, and some require a copy of the applicant's photo identification. 

After the applicant has completed all applicable out of state forms, they are to send them - along with their completed Child Care Fingerprint Sample Registration/Criminal/Juvenile History & State Registry Review Disclosure form - to the Nashville Department of Human Services office. Note that California requires the applicant to send their completed California form directly to California. In this case, the applicant is also required to submit to the Nashville Department of Human Services office a copy of the California-addressed envelope in which the applicant mailed the California form to California as proof that the applicant mailed this form to California. Unless directions specify an original form is required, each applicant’s forms should be submitted to our office, together, by email: ccbackground.dhs@tn.gov or fax: 615-532-9956. Applicant’s having state forms that are required to be original should mail all of their paperwork to:

Tennessee Department of Human Services
Attn: OIG - Background Unit
James K. Polk Building, 15th Floor
505 Deaderick Street
Nashville, TN 37243

The state of Tennessee covers all fees for Tennessee Department of Human Services fingerprinting and all out of state background checks that require a fee.

Commonly Used Acronyms

CAN = Child Abuse and Neglect Registry
N/A = Not Applicable
TBD = To Be Determined
VPR = Vulnerable Persons Registry (or equivalent)

Instructions:

Each state is categorized in alphabetical order in the box below. Please select a state(s) from the tabs at the top of the box with the corresponding first letter of the state(s) for which you are searching. Please be sure to read all information regarding your selected state as information can vary between states. Some states may return forms unprocessed if information is missing or unreadable. In addition to any required forms for other states, each applicant must submit a Child Care Criminal/Juvenile History & State Registry Review Disclosure Form. 

Return any required forms to DHS via the options listed below:

Important Note: ONLY SEND FORMS WITH PERSONALLY IDENTIFIABLE INFORMATION USING A SECURE METHOD.

  • FAX: 615-532-9956 This is a dedicated fax that goes directly to the registry check processing unit.
  • MAILING ADDRESS: Tennessee Department of Human Services, ATTN: OIG - Background Unit, James K. Polk Building, 15th Floor 505 Deaderick Street Nashville, TN 37243
  • EMAIL: Use the mailbox below for general communications about the background check process. DO NOT USE THE MAILBOX TO SEND PERSONALLY IDENTIFIABLE INFORMATION UNLESS YOU HAVE THE ABILITY TO SEND SECURE EMAIL. CCBackground.DHS@tn.gov


Additional Information:

As the volume of registry check requests to other states increases, other states may change their process/forms to better accommodate those requests. Therefore, we will update this information as needed to reflect any changes in the process. If you require additional information about the background check process, you can contact us via the dedicated phone line at: (615) 253-4170.

Alabama

Checklist: Alabama Checklist

Form: for CAN and Criminal

  • Complete disclosure form: https://www.tn.gov/content/dam/tn/human-services/documents/New%20TN%20Disclosure%20Form%20(rev.%2010-2022)template.pdf
  • Complete the Alabama form: https://www.tn.gov/content/dam/tn/human-services/documents/AL_Form_1598.pdf
  • *Please note the following when completing the Alabama form*:
  • Alabama requires the original form (not a copy, but originally written on in ink).
  • Please make sure to include full name; ex. last name, first name, full middle name, no initials accepted.
  • Please make sure to include applicant’s job/role.
  • Please make sure to include date of birth for all spouse, former spouse, children, and stepchildren listed.
  • Please make sure to include all Alabama counties where applicant lived, worked, or attended school.
  • Alabama requires a witness signature.   
    • Applicant and witness signature dates must match.
  • Please do NOT send this form to Alabama. Please send the original form TN DHS, and TN DHS will send it to Alabama.

Mail a copy of the checklist, disclosure form and original Alabama form to:
Tennessee Department of Human Services
ATTN: Basem Girgis / OIG Background Unit
James K. Polk Building, 15th Floor
505 Deaderick Street
Nashville, TN 37243

*Disclaimer: Please do not send forms for applicants until at least one day after their fingerprints have been completed. Please also send all forms for each applicant, together, including the checklist.

______________________________________________________________________________________________________________

Alaska

Checklist: Alaska Checklist

Forms: For CAN and Criminal

Email, fax or mail checklist, disclosure form and Alaska form to:
Email: ccbackground.dhs@tn.gov
Fax: 615-532-9956

Mail:
Tennessee Department of Human Services
ATTN: Basem Girgis / OIG Background Unit
James K. Polk Building, 15th Floor
505 Deaderick Street
Nashville, TN 37243

*Disclaimer: Please do not send forms for applicants until at least one day after their fingerprints have been completed. Please also send all form, for each applicant together, including the checklist.

______________________________________________________________________________________________________________

American Samoa

American Samoa

Checklist: American Samoa Checklist

Forms: For CAN and Criminal

Email, fax, or mail checklist, disclosure form to:
Email: ccbackground.dhs@tn.gov
Fax: 615-532-9956

Mail:
Tennessee Department of Human Services
ATTN: Basem Girgis / OIG Background Unit
James K. Polk Building, 15th Floor
505 Deaderick Street
Nashville, TN 37243

*Disclaimer: Please do not send forms for applicants until at least one day after their fingerprints have been completed. Please also send all forms for each applicant together, including the checklist.

______________________________________________________________________________________________________________

Arizona

Checklist: Arizona Checklist

Forms: For CAN and Criminal

Complete disclosure form: https://www.tn.gov/content/dam/tn/human-services/documents/New%20TN%20Disclosure%20Form%20(rev.%2010-2022)template.pdf

Complete Arizona form: https://www.tn.gov/content/dam/tn/human-services/documents/Arizona.pdf

Please do NOT send this form to Arizona. Please send it to TN DHS, and TN DHS will send it to Arizona.

Email, fax or mail checklist, disclosure form and Arizona form to:
Email: ccbackground.dhs@tn.gov
Fax: 615-532-9956

Mail:
Tennessee Department of Human Services
ATTN: Basem Girgis / OIG Background Unit
James K. Polk Building, 15th Floor
505 Deaderick Street
Nashville, TN 37243

*Disclaimer: Please do not send forms for applicants until at least one day after their fingerprints have been completed. Please also send all forms for each applicant together, including the checklist.

______________________________________________________________________________________________________________

Arkansas

Checklist: Arkansas Checklist

Forms: For CAN and Criminal

AND

Email, fax or mail the checklist, disclosure form and both Arkansas forms to:
Email: ccbackground.dhs@tn.gov
Fax: 615-532-9956

Mail:
Tennessee Department of Human Services
ATTN: Basem Girgis / OIG Background Unit
James K. Polk Building, 15th Floor
505 Deaderick Street
Nashville, TN 37243

*Disclaimer: Please do not send forms for applicants until at least one day after their fingerprints have been completed. Please also send all forms for each applicant together, including the checklist.

______________________________________________________________________________________________________________

California

Checklist: California Checklist

Form: for CAN and Criminal

  • Complete disclosure form: https://www.tn.gov/content/dam/tn/human-services/documents/New%20TN%20Disclosure%20Form%20(rev.%2010-2022)template.pdf
  • Complete California form: https://www.tn.gov/content/dam/tn/human-services/documents/California.pdf
  • Please do not leave any section of the California Child Abuse Central Index Self Inquiry Request form blank. If something does not apply, please enter N/A in that section.
  • The California form will need to be notarized.
  • Make two copies of notarized California Child Abuse Central Index Self Inquiry Request form.
    • Keep original notarized California Child Abuse Central Index Self Inquiry Request form on file.
  • Applicant mails one copy of the notarized California Child Abuse Central Index Self Inquiry Request form directly to California with their return address on the envelope.
    • *Please note that ONLY the notarized California Child Abuse Central Index Self Inquiry Request form needs to be mailed to California – nothing else should be mailed.
    • *Please also note that ONLY the applicant’s name and personal return address should be listed on the envelope (if the center’s information is listed, the request will not be completed by California).
    • **Please take a photo of the California-addressed/stamped envelope with the applicant’s name and personal return address listed – this photo must be sent to TN DHS along with all other necessary documents.

Email, fax or mail the checklist, disclosure form, copy of notarized California Child Abuse Central Index Self Inquiry Request form and copy of envelope the California form was mailed to California in to:
Email: ccbackground.dhs@tn.gov
Fax: 615-532-9956

Mail:
Tennessee Department of Human Services
ATTN: Basem Girgis / OIG Background Unit
James K. Polk Building, 15th Floor
505 Deaderick Street
Nashville, TN 37243

Email, fax or mail a copy of the California results to our office, as soon as possible, after they have been received.

*Disclaimer: Please do not send forms for applicants until at least one day after their fingerprints have been completed. Please also send all forms for each applicant together, including the checklist.

______________________________________________________________________________________________________________

Colorado

Checklist: Colorado Checklist

Form: for CAN and Criminal

Email, fax or mail checklist, disclosure form, clear copy of driver’s license and typed Colorado form to:
Email: ccbackground.dhs@tn.gov
Fax: 615-532-9956

Mail:
Tennessee Department of Human Services
ATTN: Basem Girgis / OIG Background Unit
James K. Polk Building, 15th Floor
505 Deaderick Street
Nashville, TN 37243

 

*Disclaimer: Please do not send forms for applicants until at least one day after their fingerprints have been completed. Please also send all forms for each applicant together, including the checklist.

______________________________________________________________________________________________________________

Connecticut  

Checklist: Connecticut Checklist

Forms: For CAN and Criminal

Email, fax or mail checklist, disclosure form, clear copy of driver’s license and typed Colorado form to:
Email: ccbackground.dhs@tn.gov
Fax: 615-532-9956

Mail:
Tennessee Department of Human Services
ATTN: Basem Girgis / OIG Background Unit
James K. Polk Building, 15th Floor
505 Deaderick Street
Nashville, TN 37243

*Disclaimer: Please do not send forms for applicants until at least one day after their fingerprints have been completed. Please also send all forms for each applicant together, including the checklist.

______________________________________________________________________________________________________________

Delaware

Checklist: Delaware Checklist

Forms: For CAN and Criminal

Email, fax or mail checklist, disclosure form, clear copy of driver’s license and typed Colorado form to:
Email: ccbackground.dhs@tn.gov
Fax: 615-532-9956

Mail:
Tennessee Department of Human Services
ATTN: Basem Girgis / OIG Background Unit
James K. Polk Building, 15th Floor
505 Deaderick Street
Nashville, TN 3724

*Disclaimer: Please do not send forms for applicants until at least one day after their fingerprints have been completed. Please send all forms for each applicant together, including the checklist.

Florida

Checklist: Florida Checklist

Form: for CAN and Criminal 

Email, fax or mail checklist, disclosure form and Florida form to:
Email: ccbackground.dhs@tn.gov
Fax: 615-532-9956

Mail:
Tennessee Department of Human Services
ATTN: Basem Girgis / OIG Background Unit
James K. Polk Building, 15th Floor
505 Deaderick Street
Nashville, TN 37243

*Disclaimer: Please do not send forms for applicants until at least one day after their fingerprints have been completed. Please also send all forms for each applicant together, including the checklist.

______________________________________________________________________________________________________________

Georgia

Checklist: Georgia Checklist 

Forms: For CAN and Criminal

Email, fax, or mail checklist, Georgia form, and disclosure form to:
Email: ccbackground.dhs@tn.gov
Fax: 615-532-9956

Mail:
Tennessee Department of Human Services
ATTN: Basem Girgis / OIG Background Unit
James K. Polk Building, 15th Floor
505 Deaderick Street
Nashville, TN 37243

*Disclaimer: Please do not send forms for applicants until at least one day after their fingerprints have been completed. Please send all forms for each applicant together, including the checklist.

______________________________________________________________________________________________________________

Guam

Checklist: Guam Checklist

Forms: For CAN and Criminal

Email, fax or mail checklist, Guam form and disclosure form to:
Email: ccbackground.dhs@tn.gov
Fax: 615-532-9956

Mail:
Tennessee Department of Human Services
ATTN: Basem Girgis / OIG Background Unit
James K. Polk Building, 15th Floor
505 Deaderick Street
Nashville, TN 37243

*Disclaimer: Please do not send forms for applicants until at least one day after their fingerprints have been completed. Please also send all forms for each applicant together, including the checklist.

______________________________________________________________________________________________________________

Hawaii

Checklist: Hawaii Checklist

Forms: For CAN and Criminal

Mail a copy of the checklist, disclosure form and original Hawaii form to:
Tennessee Department of Human Services
ATTN: Basem Girgis / OIG Background Unit
James K. Polk Building, 15th Floor
505 Deaderick Street
Nashville, TN 37243

*Disclaimer: Please do not send forms for applicants until at least one day after their fingerprints have been completed. Please send all forms for each applicant together, including the checklist.

Idaho

Checklist: Idaho Checklist

Form: for CAN and Criminal

Email, fax or mail checklist, disclosure form and Idaho form to:
Email: ccbackground.dhs@tn.gov
Fax: 615-532-9956

Mail:
Tennessee Department of Human Services
ATTN: Basem Girgis / OIG Background Unit
James K. Polk Building, 15th Floor
505 Deaderick Street
Nashville, TN 37243

*Disclaimer: Please do not send forms for applicants until at least one day after their fingerprints have been completed. Please also send all forms for each applicant together, including the checklist.

______________________________________________________________________________________________________________

Illinois

Checklist: Illinois Checklist

Form: for CAN and Criminal

Email, fax or mail checklist, disclosure form and Illinois forms to:
Email: ccbackground.dhs@tn.gov
Fax: 615-532-9956

Mail:
Tennessee Department of Human Services
ATTN: Basem Girgis / OIG Background Unit
James K. Polk Building, 15th Floor
505 Deaderick Street
Nashville, TN 37243

*Disclaimer: Please do not send forms for applicants until at least one day after their fingerprints have been completed. Please also send all forms for each applicant together, including the checklist.

______________________________________________________________________________________________________________

Indiana

Checklist: Indiana Checklist

Forms: for CAN and Criminal

Email, fax or mail checklist and disclosure form to:
Email: ccbackground.dhs@tn.gov
Fax: 615-532-9956

Mail:
Tennessee Department of Human Services
ATTN: Basem Girgis / OIG Background Unit
James K. Polk Building, 15th Floor
505 Deaderick Street
Nashville, TN 37243

Applicant completes online Indiana form, sent to applicant’s email, after disclosure form has been received in our office

*Disclaimer: Please do not send forms for applicants until at least one day after their fingerprints have been completed. Please also send all forms for each applicant together, including the checklist.

______________________________________________________________________________________________________________

Iowa

Checklist: Iowa Checklist

Forms: for CAN and Criminal

Email, fax or mail checklist, disclosure form and Iowa form to:
Email: ccbackground.dhs@tn.gov
Fax: 615-532-9956

Mail:
Tennessee Department of Human Services
ATTN: Basem Girgis / OIG Background Unit
James K. Polk Building, 15th Floor
505 Deaderick Street
Nashville, TN 37243

*Disclaimer: Please do not send forms for applicants until at least one day after their fingerprints have been completed. Please also send all forms for each applicant together, including the checklist.

______________________________________________________________________________________________________________

Kansas

Checklist: Kansas Checklist

Form: for CAN and Criminal

AND

Email, fax or mail the checklist, disclosure form and both Kansas forms to:
Email: ccbackground.dhs@tn.gov
Fax: 615-532-9956

Mail:
Tennessee Department of Human Services
ATTN: Basem Girgis / OIG Background Unit
James K. Polk Building, 15th Floor
505 Deaderick Street
Nashville, TN 37243

 

*Disclaimer: Please do not send forms for applicants until at least one day after their fingerprints have been completed. Please send all forms for each applicant together, including the checklist.

______________________________________________________________________________________________________________

Kentucky

Checklist: Kentucky Checklist

Form: for CAN and Criminal

Email, fax or mail the checklist, disclosure form and both Kentucky forms to:
Email: ccbackground.dhs@tn.gov
Fax: 615-532-9956

Mail:
Tennessee Department of Human Services
ATTN: Basem Girgis / OIG Background Unit
James K. Polk Building, 15th Floor
505 Deaderick Street
Nashville, TN 37243

*Disclaimer: Please do not send forms for applicants until at least one day after their fingerprints have been completed. Please also send all forms for each applicant together, including the checklist.

______________________________________________________________________________________________________________

Louisiana

Checklist: Louisiana Checklist

Form: for CAN and Criminal

Email, fax or mail the checklist, disclosure form and both Louisiana forms to:
Email: ccbackground.dhs@tn.gov
Fax: 615-532-9956

Mail:
Tennessee Department of Human Services
ATTN: Basem Girgis / OIG Background Unit
James K. Polk Building, 15th Floor
505 Deaderick Street

*Disclaimer: Please do not send forms for applicants until at least one day after their fingerprints have been completed. Please also send all forms for each applicant together, including the checklist.

______________________________________________________________________________________________________________

Maine

Checklist: Maine Checklist

Form: for CAN and Criminal

Email, fax or mail the checklist, disclosure form and both Maine forms to:
Email: ccbackground.dhs@tn.gov
Fax: 615-532-9956

Mail:
Tennessee Department of Human Services
ATTN: Basem Girgis / OIG Background Unit
James K. Polk Building, 15th Floor
505 Deaderick Street

*Disclaimer: Please do not send forms for applicants until at least one day after their fingerprints have been completed. Please send all forms for each applicant together, including the checklist.

______________________________________________________________________________________________________________

Maryland

Checklist: Maryland Checklist

Forms: for CAN and Criminal

 

  • *Please note the following when completing the Maryland form*:
  • Maryland requires that the form be typed.
  • Maryland requires the form to be notarized.
  • Maryland requires the original form (not a copy, but originally written on in ink).
    • Please do NOT send this form to Maryland. Please send it to TN DHS, and TN DHS will send it to Maryland.

Mail:
Tennessee Department of Human Services
ATTN: Basem Girgis / OIG Background Unit
James K. Polk Building, 15th Floor
505 Deaderick Street

*Disclaimer: Please do not send forms for applicants until at least one day after their fingerprints have been completed. Please also send all forms for each applicant together, including the checklist.

______________________________________________________________________________________________________________

Massachusetts

Checklist: Massachusetts Checklist

Form: for CAN and Criminal

Email, fax or mail the checklist, disclosure form and both Massachusetts forms to:
Email: ccbackground.dhs@tn.gov
Fax: 615-532-9956

Mail:
Tennessee Department of Human Services
ATTN: Basem Girgis / OIG Background Unit
James K. Polk Building, 15th Floor
505 Deaderick Street

*Disclaimer: Please do not send forms for applicants until at least one day after their fingerprints have been completed. Please also send all forms for each applicant together, including the checklist.

______________________________________________________________________________________________________________

Michigan

Checklist: Michigan Checklist

Form: for CAN and Criminal

Email, fax or mail the checklist, disclosure form and both Michigan forms to:
Email: ccbackground.dhs@tn.gov
Fax: 615-532-9956

Mail:
Tennessee Department of Human Services
ATTN: Basem Girgis / OIG Background Unit
James K. Polk Building, 15th Floor
505 Deaderick Street

*Disclaimer: Please do not send forms for applicants until at least one day after their fingerprints have been completed. Please also send all forms for each applicant together, including the checklist.

______________________________________________________________________________________________________________

Minnesota

Checklist: Minnesota Checklist

Form: for CAN and Criminal

Email, fax or mail the checklist, disclosure form and both Minnesota forms to:
Email: ccbackground.dhs@tn.gov
Fax: 615-532-9956

Mail:
Tennessee Department of Human Services
ATTN: Basem Girgis / OIG Background Unit
James K. Polk Building, 15th Floor
505 Deaderick Street

*Disclaimer: Please do not send forms for applicants until at least one day after their fingerprints have been completed. Please also send all forms for each applicant together, including the checklist.

______________________________________________________________________________________________________________

Mississippi

Checklist: Mississippi Checklist

Form: for CAN and Criminal

Mississippi Department of Health
Criminal History Record Check Unit
Attn: Julie Henderson
143B LeFleurs Square
Jackson, MS. 39211

  • Also, please email or fax a copy of the applicant’s ink fingerprint card, a clear copy of the applicant’s driver’s license, Mississippi checklist and completed disclosure form to:

Email: ccbackground.dhs@tn.gov

Fax: 615-532-9956

  • When the disclosure form, driver’s license, and copy of the ink fingerprint card are received in the Nashville DHS office, an online Mississippi DocuSign form will be emailed to the applicant’s email address listed on their disclosure form. Please have the applicant watch for this Mississippi DocuSign form in their inbox and junk/spam folders.
  • Applicant completes and submits the online Mississippi Child Abuse Registry Check DocuSign Form

 

*Mailing the hardcopy ink fingerprint card (cannot be bent) via USPS Priority Mail, FedEx, or UPS with a tracking number is recommended.

 

*TN DHS does not cover the payment for the hardcopy ink fingerprint to be completed or the mail delivery services*

*Disclaimer: Please do not send forms for applicants until at least one day after their fingerprints have been completed. Please also send all forms for each applicant together, including the checklist.

______________________________________________________________________________________________________________

Missouri

Checklist: Missouri Checklist

Form: for CAN and Criminal

  • Applicant completes disclosure form: https://www.tn.gov/content/dam/tn/human-services/documents/New%20TN%20Disclosure%20Form%20(rev.%2010-2022)template.pdf
  • Provider must check whether the applicant is registered in MO’s system (each applicant only needs to be registered once – they will not need to be registered each time a Missouri Background Screening Request is needed).
  • Please call 866-422-6872 to verify if applicant is registered (if the applicant needs to be registered, MO will tell you how to do that).
  • Please note that if you do have to register the applicant, there is a $14 fee – TN DHS is not authorized to cover or reimburse this fee.
  • If the applicant is registered in the system, simply request their background check over the phone (same phone number: 866-422-6872).
  • Please Email, fax or mail a copy of the checklist, disclosure form and Missouri Screening results to our Nashville DHS office:

Email, fax or mail the checklist, disclosure form and both Missouri forms to:
Email: ccbackground.dhs@tn.gov
Fax: 615-532-9956

Mail:
Tennessee Department of Human Services
ATTN: Basem Girgis / OIG Background Unit
James K. Polk Building, 15th Floor
505 Deaderick Street

 

*Disclaimer: Please do not send forms for applicants until at least one day after their fingerprints have been completed. Please also send all forms for each applicant together, including the checklist.

______________________________________________________________________________________________________________

Montana

Checklist: Montana Checklist

  • The Montana form must be notarized.
  • Please do NOT send this form to Montana. Please send it to TN DHS, and TN DHS will send it to Montana.

Email, fax or mail the checklist, disclosure form and both Montana forms to:
Email: ccbackground.dhs@tn.gov
Fax: 615-532-9956

Mail:
Tennessee Department of Human Services
ATTN: Basem Girgis / OIG Background Unit
James K. Polk Building, 15th Floor
505 Deaderick Street

*Disclaimer: Please do not send forms for applicants until at least one day after their fingerprints have been completed. Please also send all forms for each applicant together, including the checklist.

Nebraska

Checklist: Nebraska Checklist

Form: for CAN and Criminal

Email, fax or mail checklist and disclosure form to:
Email: ccbackground.dhs@tn.gov
Fax: 615-532-9956

Mail:
Tennessee Department of Human Services
ATTN: Basem Girgis / OIG Background Unit
James K. Polk Building, 15th Floor
505 Deaderick Street
Nashville, TN 37243

  • Once the disclosure form has been received by TN DHS, the online Nebraska form will be sent to the applicant email. Please have applicant complete the form on a computer if possible.

*Disclaimer: Please do not send forms for applicants until at least one day after their fingerprints have been completed. Please also send all forms for each applicant together, including the checklist.

______________________________________________________________________________________________________________

Nevada

Checklist: Nevada Checklist

Form: for CAN and Criminal

Please do NOT send this form to Nevada. Please send it to TN DHS, and TN DHS will send it to Nevada.

 

1.       Complete Nevada Criminal History Release Form: NV Criminal Release Form

 

  • Do not send this form to TrueScreen – TN DHS will send it to TrueScreen.
  • Please note: Nevada requires a set of ink fingerprints to be completed on a hardcopy fingerprint card.
    • Obtain proof of identity via 1 fingerprint card complete with name, date of birth, place of birth, sex, race, height, weight, hair color, and eye color. Fingerprints should be placed on a standard fingerprint card FD-258. Please note that the fingerprint card must contain all ten fingerprints taken simultaneously (these are sometimes referred to as plain or flat impressions) and your signature must be on the card. Fingerprints must be taken, dated, and signed by a certified fingerprinting technician. Only an original card will be accepted – please do not submit copies or previously processed card.

Mail the checklist, disclosure form, notarized Nevada form, Nevada Criminal Release Form, and original hardcopy ink fingerprint card to:

Mail:
Tennessee Department of Human Services
ATTN: Basem Girgis / OIG Background Unit
James K. Polk Building, 15th Floor
505 Deaderick Street
Nashville, TN 37243

*Disclaimer: Please do not send forms for applicants until at least one day after their fingerprints have been completed. Please send all forms for each applicant together, including the checklist.

______________________________________________________________________________________________________________

New Hampshire

Checklist: New Hampshire Checklist

Form: for CAN and Criminal

 

  • New Hampshire requires the original form.

Mail checklist, disclosure form and notarized original New Hampshire form to:

Mail:
Tennessee Department of Human Services
ATTN: Basem Girgis / OIG Background Unit
James K. Polk Building, 15th Floor
505 Deaderick Street
Nashville, TN 37243

*Disclaimer: Please do not send forms for applicants until at least one day after their fingerprints have been completed. Please also send all forms for each applicant together, including the checklist.

______________________________________________________________________________________________________________

New Jersey

Checklist: New Jersey Checklist

Form: for CAN and Criminal

Email, fax or mail checklist and disclosure form to:
Email: ccbackground.dhs@tn.gov
Fax: 615-532-9956

Mail:
Tennessee Department of Human Services
ATTN: Basem Girgis / OIG Background Unit
James K. Polk Building, 15th Floor
505 Deaderick Street
Nashville, TN 37243

*Disclaimer: Please do not send forms for applicants until at least one day after their fingerprints have been completed. Please also send all forms for each applicant together, including the checklist.

______________________________________________________________________________________________________________

New Mexico

Checklist: New Mexico Checklist

Form: for CAN and Criminal

Email, fax or mail checklist and disclosure form and New Mexico form to:
Email: ccbackground.dhs@tn.gov
Fax: 615-532-9956

Mail:
Tennessee Department of Human Services
ATTN: Basem Girgis / OIG Background Unit
James K. Polk Building, 15th Floor
505 Deaderick Street
Nashville, TN 37243

*Disclaimer: Please do not send forms for applicants until at least one day after their fingerprints have been completed. Please also send all forms for each applicant together, including the checklist.

______________________________________________________________________________________________________________

New York

Checklist: New York Checklist

Form: for CAN and Criminal

Mail a copy of the checklist, disclosure form and original New York form to:
Tennessee Department of Human Services
ATTN: Basem Girgis / OIG Background Unit
James K. Polk Building, 15th Floor
505 Deaderick Street
Nashville, TN 37243

*Disclaimer: Please do not send forms for applicants until at least one day after their fingerprints have been completed. Please also send all forms for each applicant together, including the checklist.

______________________________________________________________________________________________________________

North Carolina

Checklist: North Carolina Checklist

Form: for CAN and Criminal

Email, fax or mail checklist and disclosure form and North Carolina form to:
Email: ccbackground.dhs@tn.gov
Fax: 615-532-9956

Mail:
Tennessee Department of Human Services
ATTN: Basem Girgis / OIG Background Unit
James K. Polk Building, 15th Floor
505 Deaderick Street
Nashville, TN 37243

*Disclaimer: Please do not send forms for applicants until at least one day after their fingerprints have been completed. Please also send all forms for each applicant together, including the checklist.

______________________________________________________________________________________________________________

North Dakota

Checklist: North Dakota Checklist

Form: for CAN and Criminal

Email, fax or mail checklist and disclosure form and North Dakota form to:
Email: ccbackground.dhs@tn.gov
Fax: 615-532-9956

Mail:
Tennessee Department of Human Services
ATTN: Basem Girgis / OIG Background Unit
James K. Polk Building, 15th Floor
505 Deaderick Street
Nashville, TN 37243

*Disclaimer: Please do not send forms for applicants until at least one day after their fingerprints have been completed. Please also send all forms for each applicant together, including the checklist.

______________________________________________________________________________________________________________

Northern Mariana Islands

Checklist: Northern Mariana Islands Checklist

Form: for CAN and Criminal

Email, fax or mail checklist, disclosure form to:
Email: ccbackground.dhs@tn.gov
Fax: 615-532-9956

Mail:
Tennessee Department of Human Services
ATTN: Basem Girgis / OIG Background Unit
James K. Polk Building, 15th Floor
505 Deaderick Street
Nashville, TN 37243

*Disclaimer: Please do not send forms for applicants until at least one day after their fingerprints have been completed. Please send all forms for each applicant together, including the checklist.

______________________________________________________________________________________________________________

Ohio

Checklist: Ohio Checklist

Form: for CAN and Criminal

Email, fax or mail checklist and disclosure form and Ohio form to:
Email: ccbackground.dhs@tn.gov
Fax: 615-532-9956

Mail:
Tennessee Department of Human Services
ATTN: Basem Girgis / OIG Background Unit
James K. Polk Building, 15th Floor
505 Deaderick Street
Nashville, TN 37243

*Disclaimer: Please do not send forms for applicants until at least one day after their fingerprints have been completed. Please also send all forms for each applicant together, including the checklist.

______________________________________________________________________________________________________________

Oklahoma

Checklist: Oklahoma Checklist

Form: for CAN and Criminal

Email, fax or mail checklist and disclosure form and Oklahoma form to:
Email: ccbackground.dhs@tn.gov
Fax: 615-532-9956

Mail:
Tennessee Department of Human Services
ATTN: Basem Girgis / OIG Background Unit
James K. Polk Building, 15th Floor
505 Deaderick Street
Nashville, TN 37243

 

*Disclaimer: Please do not send forms for applicants until at least one day after their fingerprints have been completed. Please also send all forms for each applicant together, including the checklist.

______________________________________________________________________________________________________________

Oregon

Checklist: Oregon Checklist

Form: for CAN and Criminal

  • Please do NOT send this form to Oregon. Please send it to TN DHS, and TN DHS will send it to Oregon.

Email, fax or mail checklist and disclosure form and Oregon form to:
Email: ccbackground.dhs@tn.gov
Fax: 615-532-9956

Mail:
Tennessee Department of Human Services
ATTN: Basem Girgis / OIG Background Unit
James K. Polk Building, 15th Floor
505 Deaderick Street
Nashville, TN 37243

*Disclaimer: Please do not send forms for applicants until at least one day after their fingerprints have been completed. Please also send all forms for each applicant together, including the checklist.

______________________________________________________________________________________________________________

Pennsylvania

Checklist: Pennsylvania Checklist

Form: for CAN and Criminal

AND

Email, fax or mail checklist and disclosure form and Pennsylvania form to:
Email: ccbackground.dhs@tn.gov
Fax: 615-532-9956

Mail:
Tennessee Department of Human Services
ATTN: Basem Girgis / OIG Background Unit
James K. Polk Building, 15th Floor
505 Deaderick Street
Nashville, TN 37243

Disclaimer: Please do not send forms for applicants until at least one day after their fingerprints have been completed. And, please send all forms, for each applicant, together, including the checklist.

______________________________________________________________________________________________________________

Puerto Rico

Checklist: Puerto Rico Checklist

Form: for CAN and Criminal

  • The applicant’s signature date and the witness’ signature date must match.
  • Please do NOT send this form to Puerto Rico. Please send it to TN DHS, and TN DHS will send it to Puerto Rico.

Email, fax or mail checklist and disclosure form and Puerto Rico form to:
Email: ccbackground.dhs@tn.gov
Fax: 615-532-9956

Mail:
Tennessee Department of Human Services
ATTN: Basem Girgis / OIG Background Unit
James K. Polk Building, 15th Floor
505 Deaderick Street
Nashville, TN 37243

Disclaimer: Please do not send forms for applicants until at least one day after their fingerprints have been completed. And, please send all forms, for each applicant, together, including the checklist.

Rhode Island

Checklist: Rhode Island Checklist

Form: for CAN and Criminal

Email, fax or mail checklist, disclosure form and Rhode Island form to:
Email: ccbackground.dhs@tn.gov
Fax: 615-532-9956

Mail:
Tennessee Department of Human Services
ATTN: Basem Girgis / OIG Background Unit
James K. Polk Building, 15th Floor
505 Deaderick Street
Nashville, TN 37243

*Disclaimer: Please do not send forms for applicants until at least one day after their fingerprints have been completed. Please also send all forms for each applicant together, including the checklist.

______________________________________________________________________________________________________________

South Carolina

Checklist: South Carolina Checklist

Email, fax or mail a copy of the checklist and disclosure form to:
Email: ccbackground.dhs@tn.gov
Fax: 615-532-9956

Mail:
Tennessee Department of Human Services
ATTN: Basem Girgis / OIG Background Unit
James K. Polk Building, 15th Floor
505 Deaderick Street
Nashville, TN 37243

*Disclaimer: Please do not send forms for applicants until at least one day after their fingerprints have been completed. Please also send all forms for each applicant together, including the checklist.

______________________________________________________________________________________________________________

South Dakota

Checklist: South Dakota Checklist

 

  • Please do NOT send this form to South Dakota. Please send it to TN DHS, and TN DHS will send it to South Dakota.

Email, fax or mail a copy of the checklist, disclosure form and South Dakota form to:
Email: ccbackground.dhs@tn.gov
Fax: 615-532-9956

Mail:
Tennessee Department of Human Services
ATTN: Basem Girgis / OIG Background Unit
James K. Polk Building, 15th Floor
505 Deaderick Street
Nashville, TN 37243

*Disclaimer: Please do not send forms for applicants until at least one day after their fingerprints have been completed. Please send all forms for each applicant together, including the checklist.

______________________________________________________________________________________________________________

Texas

Checklist: Texas Checklist

Form: for CAN and Criminal

Email, fax or mail a copy of the checklist, disclosure form and Texas form to:
Email: ccbackground.dhs@tn.gov
Fax: 615-532-9956

Mail:
Tennessee Department of Human Services
ATTN: Basem Girgis / OIG Background Unit
James K. Polk Building, 15th Floor
505 Deaderick Street
Nashville, TN 37243

*Disclaimer: Please do not send forms for applicants until at least one day after their fingerprints have been completed. Please send all forms for each applicant together, including the checklist.

Utah

Checklist: Utah Checklist

Form: for CAN and Criminal 

Email, fax, or mail the checklist, disclosure form, clear copy of driver’s license and Utah form to:
Email: ccbackground.dhs@tn.gov
Fax: 615-532-9956

Mail:
Tennessee Department of Human Services
ATTN: Basem Girgis / OIG Background Unit
James K. Polk Building, 15th Floor
505 Deaderick Street
Nashville, TN 37243

*Disclaimer: Please do not send forms for applicants until at least one day after their fingerprints have been completed. Please also send all forms for each applicant together, including the checklist.

______________________________________________________________________________________________________________

Vermont

Checklist: Vermont Checklist

Form: for CAN and Criminal 

Mail a copy of the checklist, disclosure form and original Vermont form to:
Tennessee Department of Human Services
ATTN: Basem Girgis / OIG Background Unit
James K. Polk Building, 15th Floor
505 Deaderick Street
Nashville, TN 37243

*Disclaimer: Please do not send forms for applicants until at least one day after their fingerprints have been completed. Please also send all forms for each applicant together, including the checklist.

______________________________________________________________________________________________________________

Virgin Islands

Checklist: Virgin Islands Checklist

Form: for CAN and Criminal 

Email, fax or mail a copy of the checklist, disclosure form and Virgin Islands form to:
Email: ccbackground.dhs@tn.gov
Fax: 615-532-9956

Mail:
Tennessee Department of Human Services
ATTN: Basem Girgis / OIG Background Unit
James K. Polk Building, 15th Floor
505 Deaderick Street
Nashville, TN 37243

*Disclaimer: Please do not send forms for applicants until at least one day after their fingerprints have been completed. Please send all forms for each applicant together, including the checklist.

______________________________________________________________________________________________________________

Virginia 

Checklist: Virginia Checklist

Form: for CAN and Criminal 

Mail a copy of the checklist, disclosure form, original Virginia form, original Virginia Criminal Release Form, and original hardcopy fingerprint card to:
Tennessee Department of Human Services
ATTN: Basem Girgis / OIG Background Unit
James K. Polk Building, 15th Floor
505 Deaderick Street
Nashville, TN 37243

*Disclaimer: Please do not send forms for applicants until at least one day after their fingerprints have been completed. Please also send all forms for each applicant together, including the checklist.

______________________________________________________________________________________________________________

Washington

Checklist: Washington Checklist

Form: for CAN and Criminal 

Email, fax or mail a copy of the checklist, disclosure form and Washington form to:
Email: ccbackground.dhs@tn.gov
Fax: 615-532-9956

Mail:
Tennessee Department of Human Services
ATTN: Basem Girgis / OIG Background Unit
James K. Polk Building, 15th Floor
505 Deaderick Street
Nashville, TN 37243

*Disclaimer: Please do not send forms for applicants until at least one day after their fingerprints have been completed. Please also send all forms for each applicant together, including the checklist.

______________________________________________________________________________________________________________

Washington D.C.

Checklist: Washington D.C. Checklist

Form: for CAN and Criminal 

Please note the following when completing the Washington D.C. form:

  • Washington D.C. requires the form to be notarized or for you to include a color copy of your driver’s license.
  • Washington D.C. requires that you do not leave any blank spaces: write “no middle name” if you don’t have one. If a middle name is an initial only, write “initial only.” If the question is not applicable, write “N/A”.
  • Washington D.C. requires the original form.
    • Please do NOT send this form to Washington D.C. Please send the original form to TN DHS, and TN DHS will send it to Washington D.C.

Mail a copy of the checklist, disclosure form and original Washington D.C. form to:
Tennessee Department of Human Services
ATTN: Basem Girgis / OIG Background Unit
James K. Polk Building, 15th Floor
505 Deaderick Street
Nashville, TN 37243

*Disclaimer: Please do not send forms for applicants until at least one day after their fingerprints have been completed. Please also send all forms for each applicant together, including the checklist.

______________________________________________________________________________________________________________

West Virginia

Checklist: West Virginia Checklist

Form: for CAN and Criminal

Please do NOT send this form to West Virginia. Please send the original form to TN DHS, and TN DHS will send it to West Virginia.

Mail a copy of the checklist, disclosure form and original West Virginia form to:
Tennessee Department of Human Services
ATTN: Basem Girgis / OIG Background Unit
James K. Polk Building, 15th Floor
505 Deaderick Street
Nashville, TN 37243

*Disclaimer: Please do not send forms for applicants until at least one day after their fingerprints have been completed. Please also send all forms for each applicant together, including the checklist.

______________________________________________________________________________________________________________

Wisconsin

Checklist: Wisconsin Checklist

Form: for CAN and Criminal 

Email, fax or mail a copy of the checklist, disclosure form and Wisconsin form to:
Email: ccbackground.dhs@tn.gov
Fax: 615-532-9956

Mail:
Tennessee Department of Human Services
ATTN: Basem Girgis / OIG Background Unit
James K. Polk Building, 15th Floor
505 Deaderick Street
Nashville, TN 37243

*Disclaimer: Please do not send forms for applicants until at least one day after their fingerprints have been completed. Please also send all forms for each applicant together, including the checklist.

______________________________________________________________________________________________________________

Wyoming

Checklist: Wyoming Checklist

Form: for CAN and Criminal 

Email, Fax, or Mail a copy of the checklist and disclosure form to:
CCBackground.DHS@tn.gov
615-532-995 (fax)
Tennessee Department of Human Services
ATTN: Basem Girgis / OIG Background Unit
James K. Polk Building, 15th Floor
505 Deaderick Street
Nashville, TN 37243

*Disclaimer: Please do not send forms for applicants until at least one day after their fingerprints have been completed. Please also send all forms for each applicant together, including the checklist.