Fingerprint Background Check Application pdf

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Form CETA -08 Revised 10 / 20 20 CONFI DENTIAL Alaska D ivision of Mot or Vehicles Background Check Authorization Print Name: (F i r s t) (Middle) (Last) Social Sec u rity Number: DOB: Driver’s License Number/State: Former N a me(s) and Dates Used: Applicant Telephone Number: Applicant Email Address: Current Address : (Stree t ) (Ci t y ) (State / Zip) Since: (Mo/Yr) Previous Address: (City) (State / Zip) From: (Mo / Yr) Plea se check the reason f or yo ur b ackground ch eck: ___ DMV E mployee; ___ Business Partner; ___ C ommercial D river ’s License; ___ School B us Driver; ___ Contractor: N ame of B usiness________________________; ____ SOA : Agen cy Name______________________ I hereby authorize t he State of Alaska, Division of Motor Vehicles (DMV) , Department of Public Safety and its designated agents and representatives to conduct a comprehensive review of my background for employment purposes , commercial driver’s license, school bus driver, and/or access to DMV records, network and/or offices (contractor) . I understand the scope of the background check may include but is not limited to the following areas: verification of social security number; current and previous residences; employment history; driving records; birth records; civil court records; public records; and crimin al history records from any criminal justice agency in any or all federal, state, county jurisdictions. Your fingerprints will be used to check the criminal history records of the Federal Bureau of Investigation (FBI) and the State of Alaska. You have the opportunity to complete or challenge the accuracy of the information contained in the FBI identification record. The procedures for obtaining a change, correction, or updating an FBI identification record are set for th in Title 28, Code of Federal Regulations (CFR) , Section 16.34. If you would like to appeal the accuracy of the information contained in the FBI identification record, please notify the DMV office within 30 days of the notification letter. The letter will give you the contact information to request a hearing and what you need to do beforehand. The State of Alaska, DMV , Department of Public S afety, and its des ignated ag ents and representatives s hall maintai n all information received f rom this au thorizati on in a c onfidential manner in order t o pr otect y our pr ivacy r ights. Additional information r egarding y our applicant privacy rights f or a national b ackground c heck c an be found a t: www.fbi.gov /services /cjis/compact -council/guiding- principles -noncriminal -justic e-applicants -p rivacy- rights . ___ I nitial th at you received a c opy o f your a pplicant privacy r ights. DMV has a uthority un der t he following F ederal R egulations a nd Alaska S tatutes to per for m a fingerprint bac kground check: 49 CFR 384.228 Commercial D river’s L icense; 6 CFR 3 7.45 R eal I D; a nd AS 28.15.0 46 School Bus Drivers. Send completed form, fees and fingerprint card to: DMV Co mpliance, 3901 Old Seward Hwy STE 101 Anchorage, AK 99503-3600 Si gnature____________________________________________________ Date______________________ See P age 2 for Spanish translation. 1 Updated 11/6/2019 NONCRIMINAL JUSTICE APPLICANT’S PRIVACY RIGHTS As an applicant who is the subject of a national fingerprint - based criminal history record check for a noncriminal justice purpose (such as an application for employment or a license, an immigration or naturalization matter, security clearance, or adoption ), you have certain rights which are discussed below. All notices must be provided to you in writing. 1 These obligations are pursuant to the Privacy Act of 1974, Title 5, United States Code (U.S.C.) Section 552a, and Title 28 Code of Federal Regulations (CFR), 50.12, among other authorities. • You must be provided an adequate written FBI Privacy Act Statement (dated 2013 or later) when you submit your fingerprints and associated personal information. This Privacy Act Sta tement must explain the authority for collecting your fingerprints and associated information and whether your fingerprints and associated information will be searc hed, shared, or retained. 2 • You must be advised in writing of the procedures for obtaining a change, correction, or update of your FBI criminal history record a s set forth at 28 CFR 16.34. • You must be provided the opportunity to complete or challenge the accuracy of the information in your FBI criminal history record (if you have such a record) . • If you have a criminal history record, you should be afforded a reasonable amount of time to correct or complete the recor d (or decline to do so) before the officials deny you the employment , license, or other benefit based on information in the FBI criminal history record. • If agency policy permits, the officials may provide you with a copy of your FBI criminal history record for review and possible challenge. If agency policy does not permit it to provide you a copy of the record, you may obtain a copy of the record by submitting fingerprints and a fee to the FBI. Information regarding this process may be obtained at https://www.fbi.gov/services/cjis/identity - history - summary - checks and https://www.edo.cjis.gov . • If you decide to challenge the accuracy or completeness of your FBI criminal history record, you should send your challenge to the agency that contributed the questioned information to the FBI. Alternatively, you may send your challenge directly to the FBI by submitting a request via https://www.edo.cjis.gov . The FBI will then forward your challenge to the agency that contributed the questioned information and request the agency to verify or correct the challenged entry. Upon receipt of an offi cial communication from that agency, the FBI will make any necessary changes/corrections to your record in accordance with the information supplied by that agency. (See 28 CFR 16.30 through 16.34.) • You have the right to expect that officials receiving the results of the criminal history record check will use it only for authorized purposes and will not retain or disseminate it in violation of federal statute, regulation or executive order, or rule, procedure or standard established by the National Crime Pr evention and Privacy Compact Council . 3 1 Written notification includes electronic notification, but excludes oral notification. 2 https://www.fbi.gov/services/cjis/compact - council/privacy - act - statement 3 See 5 U.S.C. 552a(b); 28 U.S.C. 534(b); 34 U.S.C. § 40316 (formerly cited as 42 U.S.C. § 14616 ) , Article IV(c); 28 CFR 20.21(c), 20.33(d) and 906.2(d). 2 Actualizado 6/11/2019 DERECHOS DE PRIVACIDAD DE SOLICITANTES - JUSTICIA, NO CRIMINAL Como solicitante sujeto a una indagación nacional de antecedentes criminales basado en huellas dactilares, para un propósito no criminal (tal como una solicitud para empleo o una licencia, un propósito de inmigración o naturalización, autorización de seguridad, o adopción), usted tiene ciertos derechos que se entablan a continuación. Toda notificación se le debe proveer por escrito. 1 Estas obligacion es son de acuerdo al Privacy Act of 1974, Title 5, United States Code (U.S.C.) Section 552a, y Title 28 Code of Federal Regulations (CFR), 50.12, entre otras autorizaciones. • Se le debe proveer una Declaración de la Ley de Privacidad del FBI (con fecha de 2013 o más reciente) por escrito cuando presente sus huellas digitales e información personal relacionada. La Declaración de la Ley de Privacidad debe explicar la autorización para tomar sus huellas digitales e información relaciona da y si se investigarán, compartirán, o retendrán sus huellas digitales e información relacionada. 2 • Se le debe notificar por escrito el proceso para obtener un cambio, corrección, o actualización de su historial criminal del FBI según delineado en el 28 CF R 16.34. • Se le tiene que proveer una oportunidad de completar o disputar la exactitud de la información contenida en su historial criminal del FBI (si tiene dicho historial). • Si tiene un historial criminal, se le debe dar un tiempo razonable para corregir o completar el historial (o para rechazar hacerlo) antes de que los funcionarios le nieguen el empleo, licencia, u otro beneficio basado en la información contenida en su historial criminal del FBI. • Si lo permite la política de la agencia, el func ionario le podría otorgar una copia de su historial criminal del FBI para repasarlo y posiblemente cuestionarlo. Si la política de la agencia no permite que se le provea una copia del historial, usted puede obtener una copia del historial presentando sus h uellas digitales y una tarifa al FBI. Puede obtener información referente a este proceso en https://www.fbi.gov/services/cjis/identity - history - summary - checks y https://www.edo.cjis.gov . • Si decide cuestionar la veracidad o totalidad de su historial criminal del FBI, deberá presentar sus preguntas a la agencia que contribuyó la información cuestionada al FBI. Alternativamente, pued e enviar sus preguntas directamente al FBI presentando un petición por medio de .https://www.edo.cjis.gov . El FBI luego enviará su petición a la agencia que contribuyó la información cuestionada, y solicitará qu e la agencia verifique o corrija la información cuestionada. Al recibir un comunicado oficial de esa agencia, el FBI hará cualquier cambio/corrección necesaria a su historial de acuerdo con la información proveída por la agencia. (Vea 28 CFR 16.30 al 16.34 .) • Usted tiene el derecho de esperar que los funcionarios que reciban los resultados de la investigación de su historial criminal lo usarán para los propósitos autorizados y que no los retendrán o diseminarán en violación a los estatutos, normas u órdenes ejecutivos federales, o reglas, procedimientos o normas establecidas por el National Crime Prevention and Privacy Compact Council. 3 1 La notificación por escrito incluye la notificación electrónica, pero excluye la notificación verbal. 2 https://www. fb i.g o v/services/cjis/compact - council/privacy - act - statement 3 Vea 5 U.S.C. 552a(b); 28 U.S.C. 534(b); 34 U.S.C. § 40316 (anteriormente citada como 42 U.S.C. § 14616), Article IV(c); 28 CFR 20.21(c), 20.33(d) y 906.2(d). Privacy Act Statement This privacy act statement is located on the back of the FD- 258 fingerprint card . Authority: The FBI’s acquisition, preservation, and exchange of fingerprints and associated information is generally authorized under 28 U.S.C. 534. Depending on the nature of your application, supplemental authorities include Federal statutes, State stat utes pursuant to Pub. L. 92 -544, Presidential Executive Orders, and federal regulations. Providing your fingerprints and associated information is voluntary; however, failure to do so may affect completion or approval of your application. Principal Purpo se: Certain determinations, such as employment, licensing, and security clearances, may be predicated on fingerprint -based background checks. Your fingerprints and associated information /biometrics may be provided to the employing, investigating, or other wise responsible agency, and/or the FBI for the purpose of comparing your fingerprints to other fingerprints in the FBI’s Next Generation Identification (NGI) system or its successor systems (including civil, criminal, and latent fingerprint repositories) or other available records of the employing, investigating, or otherwise responsible agency. The FBI may retain your fingerprints and associated information/biometrics in NGI after the completion of this application and, while retained, your fingerprints may continue to be compared against other fingerprint s submitted to or retained by NGI. Routine Uses: During the processing of this application and for as long thereafter as your fingerprints and associated information /biometrics are retained in NGI, your information may be disclosed pursuant to your consent, and may be disclosed without your consent as permitted by the Privacy Act of 1974 and all applicable Routine Uses as may be published at any time in the Federal Register, including the Routine Uses for the NGI system and the FBI’s Blanket Routine Uses. Routine uses include, but are not limited to, disclosures to: employing, governmental or authorized non -governmental agencies responsible for employment , contracting, licensing, security clearances, and other suitability determinations; local, state, tribal, or federal law enforcement agencies; criminal justice agencies; and agencies responsible for national security or public safety . As of 03/30/2018