Request for a Background Check via Electronic Fingerprinting · Request for a Background Check via...

Request for a Background Check via Electronic Fingerprinting The University of Toledo Police Department To schedule an appointment, please call (419) 530-4439 or (419) 530-2222 □ BCI □ FBI □ BCI & FBI Type of Photo ID & ID #: ________________________________ Address: ___________________________________________ City: _______________________________________________ State/Province: ____________________ Zip Code:________ Phone #: ____________________________________________ Complete this section ONLY if a FBI background check is needed: Sex: _______ Race: _______ Height: _______ Weight: _______ Hair: _______ Eyes: _______ Reason for background check (be specific): __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ Direct Copy Options (Select only ONE) Ohio Dept of Education Ohio Dept of Public Safety BMV Dealer Licensing Ohio State Racing Commission Dietetics Board Social Worker Board Child Care Center – Type A – ODJFS Ohio Construction Board Ohio Board of Nursing Ohio Department of Liquor Control Ohio Dept of Insurance OPOTA Respiratory Care Board Lottery Commission Ohio Board of Pharmacy Ohio Medical Board Orthotics, Prosthetics, Pedorthics Board Occupational Therapy, Physical Therapy, & Athletic Trainers Board I certify that the personal identifiers provided on this form are accurate and I voluntarily and knowingly authorize the Ohio Bureau of Criminal Identification & Investigation to conduct a criminal records check for the information related to me. I also voluntarily and knowingly authorize BCI&I to disseminate criminal arrest, conviction, and juvenile delinquency adjudication records to ___________________________________________. I voluntarily and knowingly release and discharge the Ohio Attorney General’s Office, BCI&I, and their employees from all claims and liability related to this authorized criminal record review and dissemination. __________________________________________________ Applicant’s Name (Please print) __________________________________________________ Applicant’s Signature Date __________________________________________________ Parent/Guardian Name (Please print) __________________________________________________ Parent/Guardian Signature and Date (Minor Applicants ONLY) __________________________________________________ Witness Name (Please print) __________________________________________________ Witness Signature By signing this form, the applicant acknowledges that all information on this form is accurate. Any mistakes or errors on this form are the responsibility of the applicant. Personal Information (Please print) Name: _____________________________________________ Date of Birth: _______________________________________ SSN: ______________________________________________ Email Address: ______________________________________ Address for results to be mailed to: __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________

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Transcript of Request for a Background Check via Electronic Fingerprinting · Request for a Background Check via...

Page 1: Request for a Background Check via Electronic Fingerprinting · Request for a Background Check via Electronic Fingerprinting The University of Toledo Police Department To schedule

Request for a Background Check via Electronic Fingerprinting The University of Toledo Police Department

To schedule an appointment, please call (419) 530-4439 or (419) 530-2222

□ BCI □ FBI □ BCI & FBI

Type of Photo ID & ID #: ________________________________

Address: ___________________________________________

City: _______________________________________________

State/Province: ____________________ Zip Code:________

Phone #: ____________________________________________

Reason for

_________

Ohio Dept Ohio Dept BMV DealeOhio StateDietetics BSocial WorChild Care

I certify thaCriminal Idknowingly _________Office, BCI&

_________Applicant’s

_________Parent/Gu

Personal Information (Please print)Name: _____________________________________________

Date of Birth: _______________________________________

SSN: ______________________________________________

Email Address: ______________________________________

Complete this section ONLY if a FBI background check is needed:

Sex: _______ Race: _______ Height: _______ Weight: _______ Hair: _______ Eyes: _______

background check (be specific):

_________________________________________

Direct Copy Options (Select

of Education of Public Safety r Licensing

Racing Commission oard ker Board Center – Type A – ODJFS

Ohio Construction Board Ohio Board of Nursing Ohio Department of LiquoOhio Dept of Insurance OPOTA Respiratory Care Board

t the personal identifiers provided on this form are accuraentification & Investigation to conduct a criminal records chauthorize BCI&I to disseminate criminal arrest, conviction,__________________________________. I voluntarily anI, and their employees from all claims and liability related

_________________________________________ Name (Please print)

_________________________________________ Signature Date

_________________________________________ ardian Name (Please print)

_________________________________________ ardian Signature and Date (Minor Applicants ONLY)

only ONE)

r Control

Lottery CommissionOhio Board of Pharmacy Ohio Medical Board Orthotics, Prosthetics, Pedorthics Board Occupational Therapy, Physical Therapy,

& Athletic Trainers Board

te and I voluntarily and knowingly authorize the Ohio Bureau of eck for the information related to me. I also voluntarily and

and juvenile delinquency adjudication records to d knowingly release and discharge the Ohio Attorney General’s to this authorized criminal record review and dissemination.

__________________________________________________ Witness Name (Please print)

__________________________________________________ Witness Signature

By signing this form, the applicant acknowledges that all information on this form is accurate. Any mistakes or errors on this form are the responsibility of the applicant.

Address for results to be mailed to:

__________________________________________________