Form Msc 301 Qed - Background Check Request Form (Page 4 of 7) in pdf

Form Msc 301 Qed - Background Check Request Form Page 4

Section 3 — To be completed by the QED.

23. Has the SI disclosed any adverse criminal history occurring within the past five (5) years?

Yes

If the answer is yes, you MAY NOT hire the SI on a preliminary basis pending the final

fitness determination.

If the answer is no, you may hire the SI on a preliminary basis pending the final

fitness determination.

SI being hired on a preliminary basis?

Yes

I request an expedited review for hiring on a preliminary basis. The BCU may complete a

preliminary fitness determination if fingerprints are required for this SI.

24. The SI has disclosed (check all that apply):

Out-of-state driver’s license/state ID card

Out-of-state residence

Out-of-state residence within the past five (5) years

Out-of-state criminal history

If any of the above is checked or if you have reason to believe that the SI’s

identity needs to be confirmed, fingerprints are required for this SI. If this background

check request is submitted without evidence of fingerprint submission, the BCU will

reject the request.

I am submitting one fingerprint card with this background check request.

The SI is submitting fingerprints via LiveScan.

25. QED signature:

Date:

All documents related to this background check request (including this form) should be

scanned and attached to the CRIMS record using the add/edit documents function

on the SI summary page.

Page 4 of 7

MSC 301 QED (10/12)

Form Msc 301 Qed - Background Check Request Form Page 4