Georgia Criminal History Check System (GCHEXS) Request for Username and Password Form

User Type

Director/Manager/Administrator

Owner

Full Name of User (required)

Phone Number of User (required)

Email Address of User (required)

Facility Name (required)

Facility/Provider Address (required)

No P.O. Boxes

City (required)

State (required)

Zip Code (required)

Facility/Provider License Number (If Applicable)

First Name of Owner/Administrator (required)

Last Name (required)

Phone Number of Facility (required)

Date of Signature (required)

Signature

By checking this box and typing my name above, I am electronically signing my name to receive a username and password to access GCHEXS. I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature.|

Georgia Criminal History Check System (GCHEXS) Request for Username and Password Form

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