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Background Check Form is a form used to request a background check for an application. Sometimes Background Check can also be called Background Investigation. A background check is a way of looking up and editing an individual or an organization's criminal records, commercial records and financial records. This template consists of two sections: entity information and application information.

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Background Authorization
Read the attached instructions before completing this form.
SECTION 1. ENTITY INFORMATION (COMPLETED BY DSHS STAFF, PROVIDER, APPLICANT, LICENSEE, AND/OR CONTRACTOR)
1A. GIVE NAME OF PERSON OR ENTITY
REQUESTING THIS BACKGROUND CHECK
     
1B. SEE INSTRUCTIONS: GIVE ENTIRE ADDRESS OF PERSON OR
ENTITY REQUESTING THE CHECK
     
1C. REQUIRED BY CHILDREN’S ADMINISTRATION ONLY:
GIVE NAME OF FACILITY/FOSTER HOME
     
2. NAME AND SIGNATURE OF PERSON REQUESTING THE BACKGROUND CHECK
PRINTED NAME:       SIGNATURE:
3. A. REQUIRED ONLY FOR ECONOMIC SERVICES ADMINISTRATION:
WorkFirst contract Protective Payee In-home relative In loco parentis
B. REQUIRED ONLY FOR CHILDREN’S ADMINISTRATION:
State foster care Private agency foster care Adoption DCFS relative placement Contracts
Subject of (or related to) CPS investigation Residential facility or child placing agency employee
C. REQUIRED ONLY FOR ADULT PROTECTIVE SERVICES:
Subject involved in (or related to) APS investigation per RCW 74.34
D. REQUIRED ONLY FOR DSHS STATE EMPLOYMENT:
DSHS POSITION NUMBER       (WRITE NONE IF NONE) DSHS JOB CLASSIFICATION:       PERSONNEL IDENTIFICATION NUMBER:      
Permanent appointment Non-permanent appointment Work study Volunteer Student internship Layoff On-Call
4. SEE INSTRUCTIONS: BCCU ACCOUNT NUMBER
     
5A. SEE INSTRUCTIONS: DSHS ID NUMBER OR
NAME
     
5B. FOR WEB SERVICE FINGERPRINT CHECK: BCCU INQUIRY ID NUMBER
     
SECTION 2. THIS SECTION IS FOR APPLICANT INFORMATION ONLY (THE PERSON TO BE CHECKED IS THE APPLICANT)
6. SEE INSTRUCTIONS: SOCIAL SECURITY NUMBER
     
7. PRINT YOUR DATE OF BIRTH (MM/DD/YYYY)
     
8A. SEE EXAMPLE IN INSTRUCTIONS: PRINT YOUR LAST
NAME AS IT IS NOW (WRITE NONE IF NONE)
     
SEE EXAMPLE IN INSTRUCTIONS: PRINT YOUR FIRST
NAME AS IT IS NOW (WRITE NONE IF NONE)
     
SEE EXAMPLE IN INSTRUCTIONS: PRINT YOUR MIDDLE
NAME AS IT IS NOW (WRITE NONE IF NONE)
     
8B. PRINT YOUR LAST NAME AT BIRTH
(WRITE NONE IF NONE)
     
PRINT YOUR FIRST NAME AT BIRTH
(WRITE NONE IF NONE)
     
PRINT YOUR MIDDLE NAME AT BIRTH
(WRITE NONE IF NONE)
     
9. PRINT OTHER LAST NAMES YOU HAVE USED AND LAST NAMES YOU HAVE BEEN KNOWN BY (WRITE NONE IF NONE)
     
10. PRINT YOUR NICKNAMES AND ALL OTHER FIRST NAMES YOU HAVE USED AND HAVE BEEN KNOWN BY (WRITE NONE IF NONE)
     
11A. Have you been convicted of any crime? If yes, fill in the blanks below. Add a page if you need more room................................... Yes No
Felony and gross misdemeanor crimes:       Degree:      State:      Conviction date:      
11B. Do you have charges (pending) against you for any crime?
If yes, fill in the blanks below. Add a page if you need more room..................................................................................................... Yes No
Felony and gross misdemeanor crimes:       Degree:      State:     
12. Have you ever received a notice from a court or state agency stating that you have sexually abused, physically abused,
neglected, abandoned, or exploited a child, juvenile, or adult?............................................................................................................ Yes No
13. Has a court or state agency ever denied you a contract or license; terminated, revoked or suspended your contract
or license; or have you ever given up your contract or license because a court or agency was taking action against you?................ Yes No
14. Has a court ever written an order of protection or a restraining order lasting more than 30 days against you for
abuse, neglect, financial exploitation, domestic violence, or abandonment of a vulnerable adult, juvenile, or child?......................... Yes No
15. PRINT YOUR DRIVER’S LICENSE OR STATE IDENTIFICATION NUMBER (WRITE NONE IF NONE)
     
PRINT THE NAME OF THE STATE ON YOUR LICENSE OR ID
     
16. How many years have you lived in Washington State without living in another state?       Years /       Months
17. A. PRINT THE STREET ADDRESS WHERE YOU LIVE NOW CITY STATE ZIP CODE COUNTY
                             
B. SEE INSTRUCTIONS: PRINT THE STREET ADDRESS WHERE YOU LIVED BEFORE YOUR CURRENT ADDRESS
CITY STATE ZIP CODE COUNTY
                             
C. SEE INSTRUCTIONS: GIVE THE DAYTIME AREA CODE AND TELEPHONE NUMBER WHERE YOU CAN BE REACHED
     
18. I am the person named above. If I do not tell the whole truth on this form, I understand I can be charged with perjury and I may not be allowed to
work with vulnerable adults, juveniles or children. My signature in box number 19 means:
I give DSHS permission to check my background with any governmental entity and law enforcement agency.
If a founded finding is identified, I give DSHS permission to give only my name and that a founded finding was identified to any persons or entities
in Section 1.
I give DSHS permission to give all my other background information to the persons or entities named in Section 1.
This permission is good for 90 days from the date signed. I can change my mind about this permission in writing at any time.
19. REQUIRED: YOUR SIGNATURE. YOUR PARENT OR GUARDIAN’S SIGNATURE IF YOU ARE UNDER 18. 20. REQUIRED: TODAY’S DATE (MM/DD/YYYY)
     
FOR USE BY CHILDREN’S ADMINISTRATION STAFF ONLY
DSHS 09-653 (REV. 01/2008)
Background Check Form
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