Type of Participant: DCFS Staff Private Agency Staff

Last Name: First Name: MI:

First Name Preferred:

Full SSN# (Required & Kept Confidential): Date of Birth:

Home Address:

City: State: AL AK AR AS AZ CA CO CT DC DE FL GA GU HI IA ID IL IN KS KY LA MA MD ME MH MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VI VT WA WI WV WY Zip:

Cell Phone: Work Phone:

Job Title:

Illinois.gov E-Mail:

Secondary E-Mail:

Employee Role: Intern Manager/Administrator Staff Supervisor Job Function DCFS Employee Private Agency Employee

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Job Function (Check all that apply):

Direct Service

 Specify type of work:

Intact Placement Child Protection Adoptions SCR

Licensing Staff

Foster Home

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Agency Information

Agency Name: Agency Address:

Agency City: Agency State: AL AK AR AS AZ CA CO CT DC DE FL GA GU HI IA ID IL IN KS KY LA MA MD ME MH MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VI VT WA WI WV WY Agency Zip:

Agency Phone:

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Supervisor Information

Supervisor Last Name: Supervisor First Name:

Supervisor Address:

Office Phone: Cell Phone: E-Mail:

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Document Upload

The following two documents need to be uploaded (files must be less than 5 MB):

1. A completed DCFS Form 717G



2. A copy of the front of your driver's license



(Optional) You can also upload up to 8 supplemental files to your CWEL application: