Authorization Form

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AUTHORIZATION FORM ̶ ̶
BJC v1.0 - 6/30/2014
First Name
Middle Name
Last Name
Alias/Maiden Name(s)
Social Security Number
Mailing Address (NO P.O. Boxes)
City
State
Zip
As part of the  employment  volunteer  student  credentialing process, I consent to the release of my criminal background records and motor vehicle driving records or
any search listed below by any and all states or agencies holding such records. I also agree to an investigation and the obtaining of a consumer report solely for
 employment  volunteer  student  credentialing purposes. By signing this consent, I acknowledge I have received in writing a Disclosure Regarding Procurement of a
Consumer Report. I understand that the Company named above may use this consent on multiple occasions to request such consumer reports.
This consent will remain effective until I have affirmatively revoked it.
DATE: ________ /________ /________
Signature of Applicant
BACKGROUND SEARCHES
OIG (Medicare/Medicaid Fraud & Abuse)
GSA (Federal Procurement Fraud)
**FCSR
SSN Plus (Address & Alias Name are included)
Address Verification
Alias Name Search
Government Watch List
(includes DOC Entity List & Denied Persons List, DOT Specially Designated Nationals & Blocked Persons List, DOS Proliferation List & more)
Wants & Warrants (Nationwide - extraditable only)
OFAC (Specially Designated Nationals and Blocked Persons List)
Child Abuse/Neglect –  IL**
 IA**
 KS**
 MO*
 NE**
TN
*MO Mental Health Employee Disqualification Registry
MO EDL (Employee Disqualification List)
FEDERAL COURTS - Criminal State 1: _______ 2: _______
SEX OFFENDER
Nationwide or State 1: _________
INTERNATIONAL Background Check if permanent resident outside the U.S. or worked outside the U.S., in the past 10 years
DRIVING RECORD State _________
DL# __________________________________________________
PROFESSIONAL LICENSE
 National
or
 State _________
Type: ______________________________________________ License Number: ____________________________________________
EDUCATION School Name (include campus): ________________________________________________________________________
City/State: _____________________ /______ Major: _________________________________ Graduation Date: ____ /___________
Degree Type: ____________ (BSN, B.A., etc.) Name While Attending: ____________________________________________________
If additional Verifications are needed, refer to application during data entry or document on another Background Check Request Form.
LIST CITY/COUNTY CRIMINAL SEARCHES NEEDED
States with county by county access only: CA, WV and WY
County 1:_________________State: ______
County 2:_________________State: ______
County 3:_________________State: ______
STATEWIDE CRIMINAL - A Statewide/State Repository houses records from all jurisdictions throughout the State
 AL*
 AK
 AZ
 AR*
 CO
 CT*
 DE
 DC*
 FL
 GA*
 HI
 ID**
 IN
 IA**
 KS
 KY
 LA*
 MA
 ME
 MD
 MI
 MN
 MS*
 MT
 NE
 NV*
 NH**
 NJ
 NM*
 NY*
 NC
 ND
 OH
 OK
 OR*
 PA
 RI*
 SC
 SD
 TN
 TX
 UT*
 VA*
 VT*
 WA
 WI
Note: Louisiana, Nevada & Ohio are Felony Only
 *Puerto Rico Repository (Felony Only search & requires Mother's Maiden Name & Address) _________________________________
 Illinois Healthcare-compliance with IL Healthcare Worker Background Check Act (IL Police Full-State Repository Criminal)
 MO-includes MO Sex Offender search at no additional cost (MO State Highway Patrol Full-State Repository Criminal)
***The following section is to be completed by BJC (1) after job offer is extended or (2) at time of form submission for
volunteers, students and during the credentialing process***
Will Employee's Salary Exceed $75,000?
Date of Birth
Race
Gender
 No
 Yes
 Male
 Female
*Required Form(s) & **Required Special Form(s) must be ATTACHED when ordering or faxed to 573-893-7669

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