Background Check Form PDF Details

Employers often require employees to complete background checks as part of the job application process. Background checks can include criminal record checks, credit checks, and verification of educational and employment history. Completing a background check form is one way that an applicant can provide this information to their potential employer. The form typically asks for the applicant's name, address, birthdate, Social Security number, and other contact information. It may also ask for information about the applicant's current or previous employers, criminal history, credit history, and education history. Completing a background check form is voluntary in some cases, but in most cases it is required. Applicants should read all of the instructions on the form carefully before completing it.

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QuestionAnswer
Form NameBackground Check Form
Form Length3 pages
Fillable?Yes
Fillable fields79
Avg. time to fill out16 min 37 sec
Other namesprintable background check, printable background check forms, criminal background check form pdf, templates for criminal background check form

Form Preview Example

Background Check Authorization

Section 1. Required: Applicant Information (All sections completed by the applicant, the person receiving a background check). The requesting entity will submit the applicant’s information through the online Background Check System (BCS).

1.

REQUIRED: LEGAL NAME AS IT IS LISTED ON YOUR DRIVER’S LICENSE OR GOVERNMENT ISSUED PHOTO IDENTIFICATION (ID)

 

FIRST

MIDDLE

LAST

 

 

 

 

2.

REQUIRED: OTHER ALIAS FIRST, MIDDLE,

AND LAST NAMES YOU HAVE USED

 

 

FIRST

MIDDLE

LAST

 

 

 

 

3.

REQUIRED: DATE OF BIRTH

4. REQUIRED: PHONE NUMBER

I authorize BCCU to leave a detailed

 

(MM/DD/YYYY)

(INCLUDE AREA CODE)

 

 

 

message.

 

 

 

5.

EMAIL ADDRESS

By checking this box, I consent to and authorize BCCU to email my confidential and

 

 

sensitive background check information, including a fingerprint rap sheet (if applicable),

 

 

to the email address I have provided. By NOT checking this box, BCCU will use the

 

 

mailing address provided to send me my background check information.

6.

SOCIAL SECURITY NUMBER

7A. REQUIRED: VALID DRIVER’S LICENSE

7B. REQUIRED: ISSUING STATE

 

 

OR STATE ID (WRITE NONE IF NONE)

 

8.REQUIRED: HAVE YOU LIVED IN ANY STATE OR COUNTRY OTHER THAN WASHINGTON STATE WITHIN THE LAST THREE YEARS (36 MONTHS)?

Yes

No

9. REQUIRED:

MAILING ADDRESS WHERE WE CAN SEND YOU CONFIDENTIAL INFORMATION

 

 

STREET

APT. NO.

CITY

STATE

ZIP CODE

 

 

10. REQUIRED:

PHYSICAL ADDRESS WHERE YOU LIVE NOW (WRITE “SAME” IF ADDRESS IS THE SAME AS YOUR MAILING ADDRESS)

STREET

APT. NO.

CITY

STATE

ZIP CODE

Section 2. Required: Self-Disclosure Questions for ALL convictions and pending charges from any state or jurisdiction. You must answer Questions 11A through 14. Attach Page 2 if you have crimes or pending charges. SEE INSTRUCTIONS.

11A.

Have you been convicted of any crime? If yes, complete Page 2, Section 3

Yes

11B.

Do you have charges (pending) against you for any crime? If yes, complete Page 2, Section 4

Yes

12.Has a court or state agency ever issued you an order or other final notification stating that you have

sexually abused, physically abused, neglected, abandoned, or exploited a child, juvenile, or vulnerable adult? .. Yes

13.Has a government agency ever denied, terminated, or revoked your contract or license for failing to care for children, juveniles, or vulnerable adults; or have you ever given up your contract or license because a government agency was taking action against you for failing to care for children, juveniles, or vulnerable

adults?

Yes

14.Has a court ever entered any of the following orders against you for abuse, sexual abuse, neglect,

abandonment, domestic violence, exploitation, or financial exploitation of a vulnerable adult, juvenile, or child? . Yes

Permanent vulnerable adult protection order / restraining order, either active or expired.

Sexual assault protection order.

Permanent civil anti-harassment protection order, either active or expired.

No No

No

No

No

I am the person named above. If I do not tell the whole truth on this form, I understand I can be charged with perjury and I may not be allowed to work with vulnerable adults, juveniles, or children. I understand and agree my signature in the box below means:

I give DSHS permission to check my background with any governmental entity and law enforcement agency.

My background check result may include prior self-disclosure information and fingerprint results that are contained in the DSHS Background Check System and that this information will be reported as allowed by federal or state law.

If a final finding is identified, DSHS will report only my name and that a final finding was identified on the background check result.

DSHS will give my background check result to the persons or entities requesting my background check and those persons or entities may release my background check results to other persons or entities when the law authorizes or requires DSHS to do so. Fingerprint rap sheets are provided if allowed by federal or state law.

15. REQUIRED: SIGNATURE. YOUR PARENT OR GUARDIAN’S SIGNATURE IF YOU ARE UNDER 18.

16.REQUIRED: TODAY’S DATE (MM/DD/YYYY)

BACKGROUND CHECK AUTHORIZATION

Page 1 of 3

DSHS 09-653 (REV. 09/2021)

 

Background Check Authorization

List of Crimes and Pending Charges

This page MUST be attached to Page One of the Background Check Authorization form if 11A or 11B are marked “Yes.”

Important information about answering self-disclosure questions: Your answers to self-disclosure questions become part of your background check history and are stored in the DSHS database. It is recommended that you refer to charging papers, court records, or other official documents and that you list criminal convictions, pending charges, dates, and other information exactly as they are listed in those documents.

REQUIRED: PRINT YOUR NAME AS IT IS LISTED ON YOUR DRIVER’S LICENSE OR GOVERNMENT ISSUED PHOTO ID

FIRST:

MIDDLE:

LAST:

 

 

 

REQUIRED: DATE OF BIRTH (MM/DD/YYYY)

Section 3. Question 11A. If you check YES, you must enter the crime name, degree (if any), state, conviction date, and crime information.

1. CRIME NAME

DEGREE (IF ANY) STATE

CONVICTION DATE (MM/DD/YYYY)

Other crime information: Attempted Conspiracy Domestic Violence Solicitation With Sexual Motivation

DESCRIPTION OF CRIME (REQUIRED WHEN CRIME IS COMMITTED OR CONVICTED OUTSIDE OF WASHINGTON STATE)

N/A

2. CRIME NAME

DEGREE (IF ANY) STATE

CONVICTION DATE (MM/DD/YYYY)

Other crime information: Attempted Conspiracy Domestic Violence Solicitation With Sexual Motivation

DESCRIPTION OF CRIME (REQUIRED WHEN CRIME IS COMMITTED OR CONVICTED OUTSIDE OF WASHINGTON STATE)

N/A

3. CRIME NAME

DEGREE (IF ANY) STATE

CONVICTION DATE (MM/DD/YYYY)

Other crime information: Attempted Conspiracy Domestic Violence Solicitation With Sexual Motivation

DESCRIPTION OF CRIME (REQUIRED WHEN CRIME IS COMMITTED OR CONVICTED OUTSIDE OF WASHINGTON STATE)

N/A

Section 4. Question 11B. If you check YES, you must enter the PENDING charge name, degree (if any), state, and crime information.

1. CRIME NAME

DEGREE (IF ANY)

STATE

Other crime information: Attempted Conspiracy Domestic Violence Solicitation With Sexual Motivation

DESCRIPTION OF CRIME (REQUIRED WHEN CRIME IS COMMITTED OR CONVICTED OUTSIDE OF WASHINGTON STATE)

N/A

2. CRIME NAME

DEGREE (IF ANY) STATE

CONVICTION DATE (MM/DD/YYYY)

Other crime information: Attempted Conspiracy Domestic Violence Solicitation With Sexual Motivation

DESCRIPTION OF CRIME (REQUIRED WHEN CRIME IS COMMITTED OR CONVICTED OUTSIDE OF WASHINGTON STATE)

N/A

Instructions for Completing the Background Check Authorization form, DSHS 09-653

BACKGROUND CHECK AUTHORIZATION

Page 2 of 3

DSHS 09-653 (REV. 09/2021)

 

These instructions provide general directions for completing the Background Check Authorization form. This form is used by multiple DSHS programs to meet varying background check needs. The DSHS oversight program requiring the background check may have additional instructions that you must follow.

Important: The requesting entity cannot submit your background check unless ALL required boxes are complete. Required boxes have the word “REQUIRED:” next to the box number. The requesting entity will submit your completed background check through the online Background Check System (BCS).

This form is to be completed by the applicant, the person whose background DSHS is checking.

BOX NO.

INSTRUCTIONS

1Current Legal Name: List your first, middle, and last name as they are listed on your current Driver’s License or other primary photo ID. Accepted government-issued photo ID includes any federal, state, or local government-issued ID, US military ID, US or foreign passport, or federally recognized tribal ID. Write N/A in each field that you do not have a name to enter.

2Other Alias Names: Print all other first, middle, or last names you have used. Other names include nicknames, birth names, maiden names, etc. If you have not used any other first, middle, or last names, you must enter N/A in the appropriate box. Do not leave any of the boxes blank.

3Print your date of birth listing the month, day, and year (MM/DD/YYYY).

4Phone number where you can be reached Monday through Friday between 8:00 AM to 5:00 PM. By checking the box, you are authorizing BCCU to leave a detailed message.

5By providing your email address and checking the consent box, you are giving BCCU consent to send you confidential and sensitive background check information, including a fingerprint rap sheet (if applicable). BCCU will not mail or email when no background information is found (No Record). Contact BCCU if you have questions.

6You may choose to provide your Social Security Number. Your Social Security Number helps the Background Check Central Unit (BCCU) match your name and date of birth to existing records in our database and may speed up completion of your background check.

7A

Print your Driver’s License or state-issued ID number.

7B

The state where your Driver’s License or ID was issued.

8If you have continuously lived in Washington State without living in another state or country for the last three years (36 months), answer NO. If you have lived in any state or country other than Washington State within the last three years (36 months), answer YES.

9Print your mailing address where BCCU can send you confidential information such as a copy of your background check results.

10Print your street address if it is different than your mailing address. If you street address and mailing address are the same, enter SAME.

11A

You must check YES or NO. If you check YES, complete Page 2, Section 3, List of Crimes and Pending Charges, of

 

the form by entering the crime name, degree (if any), state, and the conviction date (MM/DD/YYYY). Mark the correct

 

other crime information box or N/A. If the crime was committed outside of Washington State, provide a brief description.

 

If you need to list additional convictions, attach additional copies of Page 2, to the form. Include your name and all the

 

required information listed above.

11B

You must check YES or NO. If you check YES, you must complete Page 2, Section 4, List of Crimes and Pending

 

Charges, of the form by entering the pending charge name, degree (if any), and state. Mark the correct other crime

 

information box or N/A. If the crime was committed outside of Washington State, provide a brief description. If you

 

need to list additional pending charges, attach additional copies of Page 2, to the form. Include your name and all the

 

required information listed above.

12 – 14

Read each question carefully before answering. You must check YES or NO.

 

Question 14: Permanent means the order was issued either following a hearing or by stipulation of the parties.

15Read the statements above and sign your name as it is listed in Box 1. If you are not 18 years old, a parent or guardian must sign for you.

16Enter the month / day / year (MM/DD/YYYY) you signed Box 15.

Important Information about Answering Self-Disclosure Questions (11A-14): Your answers to self-disclosure questions become part of your background check history and are stored in the DSHS database. Self-disclosures are reported as part of your background check result like any other background check history we receive. It is important that your answers to self-disclosure questions are accurate and consistent. It is strongly recommended that you answer self-disclosure questions the same way each time you complete the Background Check Authorization form unless the question has changed or the previous answer was wrong. It is also recommended that you refer to charging papers, court records, or other official documents and that you list criminal convictions, pending charges, dates, and other information exactly as they are listed in those documents.

Questions about the Background Check Process: Contact the Background Check Central Unit (BCCU) by email bccuinquiry@dshs.wa.gov or phone at 360-902-0299.

BACKGROUND CHECK AUTHORIZATION

Page 3 of 3

DSHS 09-653 (REV. 09/2021)

 

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portion of empty spaces in background check authorization form

Please type in the appropriate details in the Yes, Yes Yes, NoNo, Yes, Yes, and REQUIRED, TODAYS, DATE, MM, DD, YYYY area.

Filling in background check authorization form stage 2

Write the necessary particulars in REQUIRED, TODAYS, DATE, MM, DD, YYYY BACKGROUND, CHECK, AUTHORIZATION, DS, HS, REV and Page, of area.

step 3 to filling out background check authorization form

The MIDDLE, LAST, DEGREE, IF, ANY STATE, CONVICTION, DATE, MM, DD, YYYY Domestic, Violence Conspiracy, Solicitation, Attempted, With, Sexual, Motivation CRIME, NAME DEGREE, IF, ANY STATE, CONVICTION, DATE, MM, DD, YYYY and Domestic, Violence field could be used to indicate the rights and responsibilities of each side.

stage 4 to entering details in background check authorization form

Look at the sections CONVICTION, DATE, MM, DD, YYYY Domestic, Violence Conspiracy, Solicitation, Attempted, With, Sexual, Motivation DEGREE, IF, ANY STATE, Domestic, Violence Conspiracy, Solicitation, Attempted, With, Sexual, Motivation CRIME, NAME and DEGREE, IF, ANY and thereafter fill them in.

CONVICTIONDATEMMDDYYYY, DomesticViolence, Conspiracy, Solicitation, Attempted, WithSexualMotivation, DEGREEIFANY, STATE, DomesticViolence, Conspiracy, Solicitation, Attempted, WithSexualMotivation, CRIMENAME, and DEGREEIFANY in background check authorization form

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