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Applicant Signature Date Crossroads Youth Services Inc. Program Name Primary Provider and Licensor Name For Office of Licensing Use Only FBI DHS/Office of Licensing Screening Approval Date Applicant First Name Middle Name Last Name Last 4 SSN 8. Fingerprints Fees For placement of a child IN CUSTODY of a public child welfare system To be completed by Live Scan Technician ONLY for Initial Screening Applicants BOX A B Code P U B L I C Live Scan Operator Name Date of Live Scan Identification and...
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