THIS NOTIFICATION SHOULD BE DETACHED AND RETAINED BY APPLICANT

FINGERPRINTS SUBMITTED WITH THIS APPLICATION WILL BE USED TO CHECK FBI CRIMINAL RECORDS

To obtain a Copy of your FBI Criminal Record: Procedures for obtaining a copy of FBI criminal history record are set forth at Title 28, Code of Federal Regulations (CFR), Section 16.30 through 16.33 or go to the FBI website at http://www.fbi.gov/about-us/cjis/background-checks

Changes, Corrections, or Updating of Federal Criminal Record: Procedures for obtaining a change, correction, or updating of an FBI criminal history record are set forth at Title 28, Code of Federal Regulations (CFR), Section 16.34 or go to the FBI website at http://www.foi.gov/about-us/cjis/background-checks

If, after viewing his/her identification record, the subject thereof believes that it is incorrect or incomplete in any respect and wish changes, corrections, or updating of the alleged deficiency, he/she should make application directly to the agency which contributed the questioned information. The subject of a record may also direct his/her challenge as to the accuracy or completeness of any entry on his/her record to the FBI, Criminal Justice Information Service (CJIS) Division, and ATTN: SCU, Mod. D2, 1000 Custer Hollow Road, Clarksburg, WV 26306. The FBI will then forward the challenge to the agency which submitted the data requesting the agency to verify or correct the challenged entry. Upon the receipt of an official communication directly from the agency which contributed the original information, the FBI CJIS Division will make any changes necessary in accordance with the information supplied by that agency

Appeal of Determination: If your determination is based on an error such as wrong person, birth date, etc., please contact Health Facility Services Criminal History determination section at 501-661-2201. You may appeal a determination error within sixty (60) days by submitting a written request to : Health Facility Services Criminal History Appeals, 5800 W. 10th Street, #400, Little Rock AR 72204. Include your contact information and a description of the error.

Arkansas Code §A.C.A. 20-38-101

Health Facility Services Background Check Application (Digital Prints)

Facility ID Number 7997371

Facility name: Elite Senior Care, LLC

Address: P.O. Box 888 Manila, AR 72442 

Facility Phone # (870) 570-0340

Job Title: CNA, PCA, Personal Care and Providing Care to Clients

ALL STATE AND FEDERAL BACKGROUND CHECKS MUST BE REQUESTED THRU ARKANSAS STATE POLICE CRIMINAL BACKGROUND CHECK SYSTEM.

This paperwork must be scanned & uploaded into Arkansas State Police Criminal Background Check System when you request a federal background check. If paperwork is incomplete, letter of determination will not be processed.

FEDERAL FINGERPRINTS MAY ONLY BE REQUESTED IF THE APPLICANT HAS NOT LIVED CONTINUOUSLY IN ARKANSAS FOR THE LAST 5 YEARS.

NAME, ADDRESS AND DATE OF BIRTH VERIFIED ON THE FOLLOWING GOVERNMENT ISSUED IDENTIFICATION STATE ID CARDOTHER (LIST) DOCUMENTS-DRIVERS LICENSE

 

PROVIDING FALSE INFORMATION ON THIS FORM is A VIOLATION OF ARKANSAS LAW AND is PUNISHABLE AS SET FORTH IN ARKANSAS CODE 5-53-103

THE QUALIFIED ENTITY (EMPLOYER) MAY RECEIVE COPIES OF THE STATE RECORD CHECK RESULTS

I understand that my personal information and fingerprints submitted by agency are used to search against criminal identification records from both Arkansas Crime Information Center (ACIC) and Federal Bureau of Investigation (FBI). I hereby authorize the release of any records to the person or agency listed above. 

I further understand ACIC and the FBI may also retain the submitted information and fingerprints as permitted by the Privacy Act of 1974, 5 USC 552a, for routine uses beyond the principal parpose listed above. 

Authority: The FBI's acquisition, preservation, and exchange of fingerprints and associated Information is generally authorized under 28 U.S.C. 534. Depending on the nature of your application, supplemental authorities include Federal statutes, State statutes pursuant to Pub. L.92-544, Presidential Executive Orders, and federal regulations. Providing your fingerprints and associated information is voluntary however, failure to do so may affect completion or approval of your application. Principal Purpose: Certain determinations, such as employment, licensing, and security clearances, may be predicated on fingerprint- based background checks. Your fingerprints and associated information/blometries may be provided to the employing, Investigating or otherwise responsible agency, and/or the FBI for the purpose of comparing your fingerprints to other fingerprints In the FBI's Next Generation Identification (NGI) system or its successor systems [including civil, criminal, and latent fingerprint repositories) or other available records of the employing, investigating, or otherwise responsible agency. The FBI may retain your fingerprints and associated Information/biometrics In NGI after the completion of this application and, while retained, your fingerprints may continue to be compared against other fingerprints submitted to or retained by NGI. Routine Uses: Daring the processing of this application and for as long thereafter as your fingerprints and associated information/biometric are retained in NGI, your Information may be disclosed pursuant to your consent, and may be disclosed without your consent as permitted by the Privacy Act of 1974 and all applicable Routine Uses as may be published at any time in the Federal Register, Including the Routine Uses for the NGI system and the FBI's Blanket Routine Uses. Routine uses include, but are not limited to, disclosures to: employing governmental or authorized non-governmental agencies responsible for employment, contracting, licensing, security clearances, and other suitability determinations; local, state, tribal, or federal law enforcement agencies; criminal justice agencies; and agencies responsible for national security or public safety.

APPLICANT TO REVIEW AND INITIAL

STATEMENT OF OATH:

I STATE ON OATH THAT THE REPRESENTATIONS MADE HEREIN ARE TRUE AND CORRECT.