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The form permits the Department, under O.C.G.A. § 7-1-1004, to secure character, ethical reputation, and financial responsibility information from credit reporting agencies, former employers, and others. It states confidentiality and limited disclosure, notes corrective and update procedures under 28 CFR 16.30–16.34, and includes Non-Criminal Justice Applicant Privacy Rights and a Privacy Act Statement for fingerprint/biometric-based checks.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/background-check-authorization-form-revised-8202026/283770/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/background-check-authorization-form-revised-8202026/283770.png","ImageObject",442,249,{"name":88,"@type":89},"Cipher","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-30","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":20},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What does the applicant authorize in this background check form?","Question",{"text":108,"@type":109},"The applicant authorizes the Georgia Department of Banking and Finance to obtain criminal history data, including an FBI criminal background check, for the named individual.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"How is the information used and handled by the Department?",{"text":113,"@type":109},"The form states the information and conviction data are used exclusively for the article’s responsibilities, kept confidential, and not disclosed except to parties with legal rights to inspect the file.",{"name":115,"@type":106,"acceptedAnswer":116},"What rights does a non-criminal justice applicant have under this form?",{"text":117,"@type":109},"The applicant must receive written notification for fingerprint/biometric use, can challenge accuracy/completeness, is informed of procedures for corrections, and should receive relevant information if an adverse employment or licensing decision is made.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},283770,1790177158,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":20,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":76,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":9},687208528416,"https://ap-avatar.wpscdn.com/davatar_9964176cb1d06d4a9deccf72a44ae3dc","Company Name (Applicant or Existing Licensee)  NMLS \\#   \nBACKGROUND CHECK AUTHORIZATION FORM  \nTO WHOM IT MAY CONCERN:  \nI hereby authorize the Georgia Department of Banking and Finance (“Department”) to obtain criminal history data for the undersigned in his/her capacity as a director, officer, principal, manager or employee of the above applicant or licensee. I understand this will be an FBI criminal background check. Also, pursuant to the provisions of Section 7-1-1004 of the Official Code of Georgia Annotated (O.C.G.A. ), the Department is authorized to secure information from credit reporting agencies, former employers or others regarding character, ethical reputation and financial responsibility. Such information and any conviction data received by the Department shall be used by the Department for the exclusive purpose of carrying out the responsibilities of this article, shall be confidential, and shall not be disclosed to another person or agency except to any person or agency which otherwise has a legal right to inspect the file. The Department will notify me if further information is required. Should the data show that a violation of O.C.G.A. § 7-1-1004 exists, I understand that the Department may take appropriate steps regarding the status of the license, as well as action against any person who does not qualify for employment under the law. Further information regarding this matter is contained in O.C.G.A. § 7-1-1004. The procedures for changing, correcting, or updating a criminal history record is set forth in Title 28, Code of Federal Regulations (CFR), Section 16.30 through 16.34. By signing this form, I also acknowledge that I have read the Privacy Rights and Privacy Act Statement for Non-Criminal Justice purposes that were included with this form.  \nA copy of this authorization shall be accepted with the same force and validity as the original.  \nAttach a current passport-type photo/headshot here.  \nMost drugstore chains provide passport photo services.  \nSignature  \nPrint Full Name  \nPrint Alias  \nDate  \nWitness  \nRevised 8/20/2026  \n** Please keep the following pages for your records **  \nNON-CRIMINAL JUSTICE APPLICANT’S PRIVACYRIGHTS  \nAs an applicant that is the subject of a Georgia only or a Georgia and Federal Bureau of Investigation (FBI) national fingerprint/biometric-based criminal history record check for a non-criminal justice purpose (such as an application for a job or license, immigration or naturalization, security clearance, or adoption), you have certain rights which are discussed below.  \n• You must be provided written notification that your fingerprints/biometrics will be used to check the criminal history records maintained by the Georgia Crime Information Center (GCIC) and the FBI, when a federal record check is so authorized.  \n• If your fingerprints/biometrics are used to conduct a FBI national criminal history check, you are provided a copy of the Privacy Act Statement that would normally appear on the FBI fingerprint card.  \n• If you have a criminal history record, the agency 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.  \n• The agency must advise you of the procedures for changing, correcting, or updating your criminal history record as set forth in Title 28, Code of Federal Regulations (CFR), Section 16.34.  \n• If you have a Georgia or FBI 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 agency denies you the job, license or other benefit based on information in the criminal history record.  \n• In the event an adverse employment or licensing decision is made, you must be informed of all information pertinent to that decision to include the contents ofthe record and the effect the record had upon the decision. Failure to provide all such information to","cbCaif3o0LDAOxFR","https://ap.wps.com/l/cbCaif3o0LDAOxFR","pdf",490153,"English","# BACKGROUND CHECK AUTHORIZATION FORM\n## Non-Criminal Justice Applicant’s Privacy Rights\n## Privacy Act Statement","[{\"question\":\"What does the applicant authorize in this background check form?\",\"answer\":\"The applicant authorizes the Georgia Department of Banking and Finance to obtain criminal history data, including an FBI criminal background check, for the named individual.\"},{\"question\":\"How is the information used and handled by the Department?\",\"answer\":\"The form states the information and conviction data are used exclusively for the article’s responsibilities, kept confidential, and not disclosed except to parties with legal rights to inspect the file.\"},{\"question\":\"What rights does a non-criminal justice applicant have under this form?\",\"answer\":\"The applicant must receive written notification for fingerprint/biometric use, can challenge accuracy/completeness, is informed of procedures for corrections, and should receive relevant information if an adverse employment or licensing decision is made.\"}]","BACKGROUND CHECK AUTHORIZATION FORM - Revised 8/20/2026 | PDF",1789619034]