Tri-State Investigations 330-788-9945
-Please read, print and complete form in full-
I certify that the personal identifiers provided on this form are accurate and I voluntarily and knowingly authorize this WebCheck Agency –Tri-State Investigations, to submit information to the Ohio Bureau of Criminal Identification and Investigation (BCII) to conduct a criminal record check. I voluntarily and knowingly authorize BCII to disseminate criminal arrest(s), conviction and juvenile delinquency 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, BCII, and their employees from all claims and liability related to this authorized criminal record review and dissemination. This authorization and waiver is valid for one (1) year from the date this background check was conducted.
Your Signature:________________________________________________________
Today’s Date:___________________________________________________________
Phone Number:_________________________________________________________
Printed Name:__________________________________________________________
Under 18 Legal Guardian’s Signature:_________________________________
Witness: Terri A. Hempstead/ Owner/Operator FEF182
What procedure do you need? FBI_______BCI________ INK________
Mail to Information:
Company Name:_________________________________________________________
Street Address:_________________________________________________________
City, State, Zip Code: __________________________________________________
Direct Send Information: Is this a direct send? Yes No
If marked Yes, where to:______________________________________________
Reason Code / ORC Code Information:
Your ORC Reason Code or Codes:_______________________________________
__________________________________________________________________________
NONCRIMINAL JUSTICE APPLICANT’S RIGHTS
As an applicant who is subject of a national fingerprint-based criminal history check for a noncriminal justice purpose (such as an application for a job or a license, an immigration or naturalization matter, security clearance, or adoption), you have certain rights which are discussed below. You must be notified by the requesting agency that your fingerprints will be used to check the criminal history records of the FBI.
- If you have a criminal history record, the officials making a determination of your suitability for the job, license, or other benefit must provide you the opportunity to complete or challenge the accuracy of the information in the record.
- The officials must advise you that the procedures for obtaining a change, correction, or updating of your criminal history record are set fourth at Title 28, Code of Federal Regulations (CFR), section 16.34
- If you have a criminal history record, you should be afforded a reasonable amount of time to correct or complete the record(or decline to do so) before the officials deny you the job, license, or other benefit based on information in the criminal history record.
You have the right to expect that officials receiving the results of the criminal history record check will use if only for authorized purposes and will not retain or disseminate it in violation of federal statue, regulation or executive order, or rule, procedure or standard established by the National Crime Prevention and Privacy Compact Council. 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/about-us/cjjs/identity-history-summary-checks. If you decide to challenge the accuracy or completeness of you fbi criminal history record, you should send your challenge to the agency that contributed the questioned information to the FBI. Alternatively you may send you challenge directly to the FBI. The FBI will then forward your challenge to the agency that contributed the questioned information and request the agency verify or correct the challenged entry. Upon receipt of an official 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) If you need additional information or assistance, please contact the Identification Quality Assurance Unit at 740-845-2113 or NationalWebcheck@ohioattorneygeneral.gov. Should you have additional questions please call the Ohio Attorney Generals office at 1-740-845-2113. 1 See 28 CFR50.12(b)2 See 5 U.S.C. 552a(b);28 U.S.C. 534(b); 42 U.S.C. 14616, Article IV(c), 20.33 (d) and 906.2 (d).
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