Request for a Background Check via Electronic Fingerprinting

Personal Information (Please print)

Complete this portion only if an FBI background check is needed:

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I certify that the personal identifiers provided on this form are accurate and I voluntarily and knowingly authorize the ohio Bureau of Ciriminal Identification & Investigation to conduct a criminal records check for the information relating to me. I also voluntarily and knowingly authorize BCI&I to disseminate criminal arrest, conviction and juvenile delinguency adjudication records to.....................I voluntarily and knowingly release and discharge the Ohio Attorney General's Office, BCI&I and their employees from all claims and liability related to this authorized criminal record review and dissemination.

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By signing this form the applicant acknowledges that all information on this form is accurate. Any mistakes or errors on this form are the responsibility of the applicant.