Background Check Authorization - Dshs (Page 3 of 3) in pdf

Example 2 – entering N/A because no other first, middle, or last names have been used.

10. REQUIRED: PRINT ALL OTHER FIRST, MIDDLE AND LAST NAMES YOU HAVE USED. WRITE N/A IN THE BOX IF YOU DON’T HAVE A NAME TO ENTER.

N/A

FIRST:

MIDDLE:

LAST:

See important information about answering self-disclosure questions following the description for Box 20.

Box No. Instructions

11A

You must check YES or NO. If you check YES, you must enter the crime name, degree (if any), state, and the

conviction date (MM/DD/YYYY). If you need to list additional convictions, attach a separate piece of paper to the

Background Check Authorization form. Include your name and all the required information listed above.

11B

You must check YES or NO. If you check YES, you must enter the pending charge name, degree (if any), and

state. If you need to list additional pending charges, attach a separate piece of paper to the Background Check

Authorization 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.

Enter your Driver’s License or state-issued ID and the state where it was issued.

If 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.

17a - Enter your mailing address where BCCU can send you confidential information such as a copy of your

background check results.

17b – Enter your street address if it is different than your mailing address. If your street address and mailing

address are the same, enter SAME.

17c – Enter the daytime phone number where you can be reached.

18.

Read the statements in Box 18. Your signature in Box 19 means you have read, understand, and agree to the

statements listed in Box 18.

19.

Sign your name as it is listed in Box 9. If you are not 18 years old, a parent or guardian must sign for you.

20.

Enter the month / day / year (MM/DD/YYYY) you signed Box 19.

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. 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.

If you have questions about the Background Check Central Unit background check process, contact BCCU at

bccuinquiry@dshs.wa.gov

or call 360-902-7555.

DSHS 09-653 (REV. 04/2015)

Background Check Authorization - Dshs Page 3

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