BACKGROUND CHECK

PLEASE COMPLETE ALL REQUIRED INFORMATION.

FNAME/LNAME

JOB TITLE

MONEY ORDER / CREDIT CARD ONLY

FBI $24

BCI $22

BOTH FBI & BCI $46

BUS DRIVERS $15

EMPLOYEE ID NUMBER (EID)

Mandatory for all Current Employees to Complete

REASON FOR BACKGROUND CHECK

LEAVE BLANK IF THE REASON FOR THE BACKGROUND CHECK DOES NOT APPLY.

IF YOU CHOOSE "OTHER" FOR REASON FOR BACKGROUND CHECK, PLEASE EXPLAIN:

INVOICE

PLEASE READ CAREFULLY:

IF THIS IS AN INVOICE, PLEASE SELECT THE APPROPRIATE DEPARTMENT.

IF THIS IS NOT AN INVOICE, PLEASE DO NOT SELECT AN OPTION.

ACCEPT TERMS AND CONDITIONS

I CERTIFY THAT THE PERSONAL IDENTIFIERS PROVIDED ON THIS FORM ARE ACCURATE AND I VOLUNTARILY AND KNOWINGLY AUTHORIZE THIS WEBCHECK AGENCY (CLEVELAND METRO SCHOOL DISTRICT (2)) TO SUBMIT INFORMATION TO THE OHIO BUREAU OF CRIMINAL IDENTIFICATION AND INVESTIGATION (BC&I) TO CONDUCT A CRIMINAL RECORDS CHECK FORM INFORMATION RELATING TO ME. I VOLUNTARILY AND KNOWINGLY AUTHORIZE BC&I TO DISSEMINATE CRIMINAL ARREST, CONVICTION AND JUVENILE DELINQUENCY ADJUDICATION RECORDS TO THE WEBCHECK PROVIDER OR AGENCY I HAVE DESIGNATED TO RECEIVE THIS INFORMATION. I VOLUNTARILY AND KNOWINGLY RELEASE AND DISCHARGE THE OHIO ATTORNEY GENERAL'S OFFICE, BC&I AND THEIR EMPLOYEES FORM ALL CLAIMS AND LIABILITY RELATED TO THIS AUTHORIZED CRIMINAL RECORD REVIEW AND DISSEMINATION. I AUTHORIZE AND WAIVER IS VALID FOR ONE YEAR FROM THE DATE THIS BACKGROUND CHECK WAS CONDUCTED.

DIRECT COPY

Please provide your Social Security Number at the time of your visit.

DATE OF BIRTH

mm/dd/yyyy

MAIL TO

TYPE OF PHOTO ID#

Enter Driver's License Number

HOME ADDRESS CITY ZIP

PHONE NUMBER

Phone

RECEIPT

PLEASE READ CAREFULLY:

A CONFIRMATION RECEIPT OF YOUR VISIT WILL BE SENT TO YOUR EMAIL. PLEASE PROVIDE YOUR EMAIL ADDRESS BEFORE SUBMITTING.

“AFTER YOU SUBMIT THIS FORM USE THE LINK IN THE CONFIRMATION TO SCHEDULE YOUR APPOINTMENT.” THANK YOU.

EMAIL ADDRESS

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