DCF Background Screening
Intent to Apply for an Exemption from Disqualification Form

ALl Fields are required and denoted by *

REQUESTOR INFORMATION
FACILITY INFORMATION
QUESTIONS

Prior to proceeding with this intent to apply for an exemption from disqualification, you must verify you understand the following information by checking the box next to each statement, sign and date this form

By clicking submit you agree you are electronically signing and dating this form and submitting this form electronically to the department