Page 2 is the List of Crimes and Pending Charges and page 3 holds the instructions.
List of Crimes: this page must be attached to Page One if 11A or 11B are marked “Yes.”
Required boxes: the requesting entity cannot submit your background check unless ALL required boxes are complete.
Under 18: if you are not 18 years old, a parent or guardian must sign for you.
Alias names: if you have not used any other first, middle, or last names, you must enter N/A in the appropriate box.
Other state or country: if you have lived in any state or country other than Washington State within the last three years (36 months), answer YES.
Questions: you must answer Questions 11A through 14.
| Question | Answer |
|---|---|
| Form Name | DSHS 09-653 |
| Form Length | 3 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 9 min |
| Edition | Rev 07/2025 |
| Matches the agency's file | Yes, checked October 3, 2026 |
| Other names | DSHS 09-653, 09-653, DSHS 09653, Background Check Authorization, Background Authorization form |
| Official source | DSHS 09-653 (Rev 07/2025) Background Check Authorization |
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