Background Fingerprint Request Form - Fairfield Local
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1Fairfield Local Schools
11611 St. Rt. 771
Leesburg, Ohio 45135
Phone: 937-780-2221 ---------- Fax: 937-780-6900
William Garrett, Superintendent
Deanne Miller, Principal K-4
Tom Dean, Asst. Principal 5-12
Steve Hackett, Principal 5-12
Request for Criminal Records Background Check – Electronic Fingerprinting
Personal Information
Name
DL#
DOB
State
SSN
Zip Code
Address
Email
City
Phone #
Type of Background Check Requested:
____ BCII
____FBI
_ BCII & FBI
Complete this portion only if an FBI Background Check is needed.
Sex
Race
Height
Weight
Eyes
Hair
Reason for Background Check:
____ School Employee~
____ School Volunteer*
_ Athletics^
SUBMIT AN ELECTRONIC COPY OF THIS BACKGROUND CHECK TO THE OHIO DEPT. OF EDUCATION.
Mail Printed Results to:
Fairfield Local School District
Superintendent’s Office
11611 St. Rt. 771
Leesburg, Ohio 45135
~School Employees are responsible for all fees associated with a Criminal Records Background Check.
*School Volunteers are authorized to charge the Criminal Records Background Checks to Fairfield Local School
District only if Background Check is performed at the Southern Ohio Educational Service Center.
^Coaches/Athletic Volunteers are responsible for all fees associated with a Criminal Records Background Check.
Applicant’s Signature: ______________________________________________ Date: ____________________
*Fairfield Local School District – Authorization to Assume Fees from the SOESC (Volunteers Only)
School Authority:
__________________________________________ Date: _____________________
School Authority Signature: ____________________________________________________________________
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