BCI/FBI Registration Form-FINERmobile

First Name

Last Name

Address

Phone Number

Email

Date of Birth (numbers only)

Social Security Number (no dashes)

Type of ID

ID #

Enter sex, race, height, weight, hair color, eye color ONLY if a FBI background check is needed:

Reason for Background Check

Address to send results to:

Direct Copy Options (SELECT ONLY ONE):

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 criminal records check for the information relating to me.

Yes

No

I also voluntarily and knowingly authorize BCI&I to disseminate criminal arrest, conviction and juvenile delinquency adjudication records to ______________________________________________________.

Yes

No

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. an option

Yes

No

Applicant Signature

*

Date

Parent/Guardian Name (minor applicants only)

Date

Witness Signature

Date

I have reviewed the FBI Noncriminal Justice Applicant's Privacy Rights letter and declined a copy.

*

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.

*