Request for a Background Check via Electronic Fingerprinting

Check one:	BCI	FBI	BCI and FBI

Personal Information (please print)

Name	

Maiden/previous married names	

Address

City	

Date of Birth: 	

SSN:	

Phone #	

Email Address: 	

State	Zip	

Complete this portion only if an FBI background check is needed:
	
	Gender
		
	Race
		
	Height
		
	Weight
		
	Hair
		Eyes

	

BCI ORC CODE:	

FBI ORC CODE:	

Reason for Background Check (Must be specific)

If reason is employment: list job title and job duties

Name and Address for results to be mailed to:

Agency:	

Attn:	

Address:	

BMV Dealer Licensing BMV Deputy Registrar
Child Care Center – Type A-ODJFS Commerce Medical Marijuana Control
Program
Lottery Commission
Occupational Therapy, Physical Therapy and Athletic Trainers Board
Ohio Board of Nursing Ohio Board of Pharmacy Ohio Construction Board

Direct Copy Options (Select ONE) Ohio Dental Board
Ohio Department of Agriculture – Hemp Program
Ohio Department of Insurance Ohio Department of Liq. Control Ohio Dept. of Education
Ohio Dept. of Public Safety Ohio Division of Real Estate and
Professional Licensing Ohio Medical Board
Ohio Racing Commission

Ohio Veterinary Medical Licensing Board OPOTA
Social Worker Board (CSWMFT)
State Speech and Hearing Professionals Board
State Vision Professionals Board

NONE

I certify that the personal identifiers provided on this form are accurate and I voluntarily and knowingly authorize the Ohio Bureau of Criminal 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 juveniledelinquency 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.

Applicant’s Name (print)	Processed by – Signature & Unit Number

Applicant’s Signature	Date	Amount Received

Parent/Guardian Name (print)

Parent Guardian Signature (Minor Applicants only)

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. NO REFUNDS.

	I have reviewed the information entered on the Webcheck screen and I verify that it is accurate.