Webcheck # ______________________________________
Log# ____________________________________________
Request for a Background Check via Electronic
Fingerprinting
BCI
FBI
BCI and FBI
Personal Information (please print)
Type of Photo ID and ID# ___________________________________________
Name
State/Province
SSN
Date of Birth
Zip/Postal Code
Phone #
Address
City
Email Address
Reason for background check:__________________________________________________________
Direct Copy to (circle only one):
Ohio Department of Education
Address for results to be mailed to:
Ohio Board of Nursing
______________________________________________________
Ohio Department of Public Safety
______________________________________________________
______________________________________________________
Ohio Department of Liquor Control
______________________________________________________
Ohio State Racing Commission
None
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 relating 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)
Witness Name (please print)
Applicant's Signature
(date)
Witness Signature
Parent/Guardian Name
By signing this form the applicant acknowledges that all
Parent/Guardian Signature (Minor Applicants only)
information on this form is accurate. Any mistakes or errors
on this form are the responsibility of the applicant.