Form Dshs 09-653 - Background Authorization Page 3
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3Background Authorization Instructions – Page 2 of 2
SECTION 2: You MUST fill out this section if you are the person we are checking. Note: A DSHS employee asking for a
background check for an Adult Protective Services (APS) or Child Protective Services (CPS) investigation MUST fill out this section as
best he or she can.
6.
You MAY put your social security number (SSN) in this box. Your SSN is not required to conduct a background check.
(This box allows your program to insert requirements.)
7. You MUST fill in your date of birth.
8A. You MUST put your whole name. If you do not have a name to put in this box, you MUST put NONE.
SEE EXAMPLE BELOW.
EXAMPLE:
PRINT YOUR LAST NAME AS IT IS NOW
PRINT YOUR FIRST NAME AS IT IS NOW
PRINT YOUR MIDDLE NAME AS IT IS NOW
NONE
“Prince”
NONE
B. You MUST put your whole birth name. You MUST put SAME if any of your names are the same as the names you put in
box 8A.
9. You MUST put last names you have used or have been known by. You MUST put NONE if you have NOT used or been known
by any other last names.
10. You MUST put any nicknames you have used. You MUST put NONE if you have NOT used any nicknames.
11. You MUST answer YES or NO. If your answer is YES to A. or B., you MUST fill in your conviction and pending charge
information.
12. You MUST answer YES or NO.
13. You MUST answer YES or NO.
14. You MUST answer YES or NO. Put YES if the protection order lasted longer than 30 days and it was for the protection of a
vulnerable adult, juvenile or child.
15. You MUST put your driver’s license or state identification number in the box. You MUST put the name of the state in the box.
You MUST put NONE if you do not have a driver’s license or state identification number.
16. You MUST put the number of years and months you have lived in Washington State without living in another state or country. If
you have moved out of Washington to another state or country, you MUST start counting the years and months from the date
you moved back to Washington State. Note: You MUST ask your program if you have to get a fingerprint check.
17. A. You MUST fill in the address where you live now.
B. Your program may require you give your old address. Ask your DSHS program. Put N/A in this box If NOT required by your
program.
(This box allows your program to insert requirements.)
C. Ask your program if your telephone number is required. You MUST put NONE if you do not have a telephone number.
(This box allows your program to insert requirements.)
18. You MUST read the statement in this box. Your signature under number 19 means you have read and agree to the
statements in number 18. This background authorization form does NOT take the place of a public disclosure
request for records about a founded finding. Founded finding means a state agency has taken a legal action
against someone after an investigation and notice of a decision about abuse, sexual abuse, neglect,
abandonment or exploitation or financial exploitation of a vulnerable adult, juvenile or child.
19.
You MUST sign your name here. If you are NOT 18 years old, your parent or guardian MUST sign here.
20. You MUST fill in the date you signed this form.
ATTENTION APPLICANTS:
If you want to know the status of your background check form or need information about the BCCU background check process, contact
BCCU at:
bccuinquiry@dshs.wa.gov
ATTENTION ENTITIES AND DSHS STAFF: You MUST report errors in your address, telephone number or fax number to BCCU at
bccuinquiry@dshs.wa.gov
or (360) 902-0299. Put your BCCU account number in your email.
DSHS 09-653 (REV. 01/2008)
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