I understand that in applying for a position involving regular contact with or control over Indian
children or any child care services position, I must undergo a background check as mandated by
the Indian Child Protection and Family Violence Prevention Act, Pub. L. 101-630, 25 U.S.C.
‘3207, and the Crime Control Act of 1990, Pub. Law 101-647,42 U.S.C. ‘13041. Child care
services positions include, but are not limited to child protective services, social services, health
and mental health care, child/day care, education whether or not directly involved in teaching,
foster care, residential care, recreational or rehabilitative programs, and detention correctional or
I certify that all the information on this form and any attached sheets is true, correct complete
and made in good faith. I understand that false or fraudulent answer to any question may be
grounds for not hiring me, or for firing me after I begin work. I understand that any information I
give may be investigated for purposes of determining my fitness to have responsibility for the
safety and well-being of children and suitability to occupy a position involving regular contact
with or control over Indian children. I consent to the release of information about my ability,
fitness and suitability for employment with the Cheyenne and Arapaho Tribes by employers,
schools, law enforcement agencies, and other individuals and organizations to investigators,
personnel, specialist, and other authorized employees of the Cheyenne and Arapaho Tribes. I
understand that financial or lending institutions, medical institutions, hospitals, health care
professionals, or some other sources of information, may require the separate Authorization for
Release of Information I have signed. I also understand that I may challenge the accuracy and
completeness of any information obtained during the investigation of my background.
Public Law 101-647 requires that the application state that it is signed under penalty of perjury,
with the applicable Federal punishment for perjury.