Request for Staff Exclusion List Check Form Providers must request 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin with Part 1: Applicant Information. Fill in the Last Name, First Name, and Social Security Number. If no SSN is available, provide the Job Title and Alien Registration Number.
3. Continue by entering the Date of Birth and Program Name & Address. Ensure you include the OCFS SACC or DCC number as it is required.
4. Move to Part 2: Authorized Person Information. Enter the Name, Work Email, Facility/Provider Name, and Phone number of the authorized person completing this form.
5. Once all fields are completed accurately, review your entries for any errors before submitting.
6. Finally, send the completed form to your licensor/registrar or fax it directly to the Justice Center’s Criminal Background Check unit as per your provider type.

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