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\nName State/Province  \nDate of Birth   SSN Zip/Postal Code    \nPhone \\#  \nAddress  \nEmail Address  \nCity  \n| Sex | Race\u003Cbr>| Weight\u003Cbr>| Hair | Eye\u003Cbr>|\n| --- | --- | --- | --- | --- |\n\nReason for background check: Xavier address for results to be mailed to:  \nDirect Copy Options (Select only one)  \nOhio Dept of Education Ohio Dept of Public Safety BMV Dealer Licensing  \nOhio State Racing Commission State Vision Professionals Board Social Worker Board  \nChild Care Center-Type A-ODJFS Ohio Construction Board  \nOhio Board of Nursing  \nOhio Department of Liquor Control  \nBMV Deputy Registrar  \nOhio Department of Insurance  \nOPOTA  \nState Speech and Hearing Professionals Board LotteryCommission  \nOhio Board of Pharmacy  \nOhio Medical Board  \nOhio Veterinary Medical Licensing Board Occupational Therapy, Physical Therapy  \nand Athletic Trainers Board  \nNONE  \nI certify that the personal identifiers provided on this form are accurate. I voluntarily and knowingly authorize XUPD to submit information to the Ohio Bureau of Criminal Identification & Investigation (BCI) and the Federal Bureau of Investigation (FBI) to conduct a criminal records check for the information relating to me. I also voluntarily and knowingly authorize the BCI to disseminate criminal arrest, conviction and juvenile delinquency adjudication records to the contact address I have selected above. I voluntarily and knowingly release and discharge the Ohio Attorney General's Office, BCI, FBI, Xavier University and the Xavier Police Department and their employees from all claims and liability related to this authorized criminal record review and dissemination. I also acknowledge that the results of this background investigation could affect my ability to participate in a Xavier University program, could affect my employment or potential employment with Xavier University or other entities or could result in a University code of conduct and/or criminal investigation.  \nApplicant's Name (please print)  \nApplicant's Signature (date)  \nFingerprint technician (please print)  \nSignature  \nPlease read and initial below :  \nI have reviewed the information entered on this form, and I acknowledge that all information provided is accurate. I also understand that any mistakes or errors on this form are my responsibility    \nI have reviewed the information entered on the WebCheck screen, and I verify that all of the information is accurate.  \n_________  \nI have reviewed the FBI Noncriminal Justice Applicant’s Privacy Rights letter. I was offered a copy of the Privacy Rights letter and:   Declined it.   Took it with me.   Requested that it be sent to me at the email address provided on this form.","cbCaisjGqFfVr8ML","https://ap.wps.com/l/cbCaisjGqFfVr8ML","pdf",120474,"English","# XUPD BCI/FBI Background Check Application\n## Applicant information\n## Background check reason and mailing option\n## Certification and authorization\n## Privacy rights acknowledgement","[{\"question\":\"What information is required from the applicant on this background check form?\",\"answer\":\"Applicants provide personal identifiers such as name, state, date of birth, SSN, phone, address, email, and city, along with optional demographic details including sex, race, weight, hair, and eye.\"},{\"question\":\"How does the applicant choose where results will be sent?\",\"answer\":\"The applicant selects one direct copy option from the listed Ohio agencies and boards, which determines the contact address used for sending results.\"},{\"question\":\"What does the certification and authorization section authorize?\",\"answer\":\"The applicant confirms the information is accurate and voluntarily authorizes XUPD to submit data to the Ohio BCI and the FBI to conduct a criminal records check and to release specific records to the selected contact address.\"}]","XUPD BCI/FBI Background Check Application - WebCheck Form | PDF",1790654306]