Background Check Waiver printable pdf download

Background Check Waiver

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Last Name, First Name, Middle Name

Date of Birth

Address

City

State

Zip Code

I hereby authorize the Nebraska Department of Revenue (Department) to submit a set of my fingerprints and this form

to the Nebraska State Patrol for the purpose of accessing and reviewing the Nebraska and FBI national criminal history

records that may pertain to me. I understand that I would be able to receive any national criminal history record that may

pertain to me directly from the FBI, pursuant to 28 CFR Sections 16.30-16.34, and that I could then freely disclose any such

information to whomever I chose. By signing this waiver, it is my intent to authorize the dissemination of any national

criminal history record that may pertain to me to the above agency.

I understand that, upon request, the Department will provide me a copy of the criminal history background report, if

any, they receive on me and that I am entitled to challenge the accuracy and completeness of any information contained in

the report.

Information on how to challenge your federal report can be found at FBI.gov. To challenge your Nebraska state record,

contact the Nebraska State Patrol-Criminal Identification Division. I may obtain a prompt determination as to the validity

of my challenge before the Department makes a final decision about my status.

sign

here

Signature of Applicant

Date

Background Check Waiver