Background Check Form - Childrens Advocacy Center Of Hidalgo Page 3
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3Texas Dept of Family
Form 1601
PERMISSION TO ALLOW CAC PROGRAM TO REQUEST
and Protective Services
May. 2012
CHILD ABUSE/NEGLECT
CENTRAL REGISTRY and DPS CRIMINAL HISTORY CHECK
FAX or E-MAIL this form to:
cactxbgcrequest@dfps.state.tx.us
Fax Number: (512) 339-5871
ATTN: CBCU Non-Licensing Unit
Send results of requested check to:
(FOR CAC PROGRAM USE ONLY)
CAC Program:
Children’s Advocacy Center of Hidalgo County, Inc “Estrella’s House”
Physical Address of Program:
525 W. Wisconsin Rd
Edinburg, TX 78596
*Required
E-mail Address of Executive Director/Authorized Representative:
I am authorized on behalf of the Children’s Advocacy Center (CAC) program listed above to make this request. I
have attached the proper form signed by the subject of this request granting permission to make this request.
I understand that the subject of this request is entitled to have the results provided to him or her and may not have
exhausted all opportunities to contest findings in the Central Registry and may have the right to challenge any such
findings.
I certify that the subject of this request is a prospective or current volunteer, employee or board member of the CAC
program.
CAC Program Executive Director/Authorized Representative:
Signature: _______________________________________
Date: ___________________________________________
Note: CBCU
will provide
all results to CAC within 30 days of receiving a completed request form. If you have not
received a response from the CBCU after 30 days of submitting the request, please send an email to
to check the status of the background check request.
cactxbgcrequest@dfps.state.tx.us
There may situations when only the results of the DPS criminal history check are sent to the CAC program. In these
situations please contact the subject of the request for the results of the FPS Central Registry check. If the subject of
the request states he/she has not received the results of the FPS Central Registry request, please have him/her
contact the CBCU via email at
cactxbgcrequest@dfps.state.tx.us
for the results.
**Notice: This document (1601) must remain on file and will be required for subsequent background check
requests.
Page 3
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