1. This form must be complete and signed. Incomplete forms may result in delays in the approval process.
2. Ensure that all writing on the form is legible. Illegible handwriting may prevent approval and cause unnecessary delays.
3. If an applicant does not possess a driver's license, they may provide their state ID number and the state of issue instead. A copy of the photo identification must be uploaded with this form.
4. A copy of the individual's application for employment must be uploaded with this form.
5. Please visit the Arkansas Department of Public Safety's website for the most current pricing information for background checks: https://www.ark.org/criminal/index.php
6. If a federal background check is required, the Provider must select the DDP- Division of Developmental Disabilities Prefix.

If "No" the applicant will be required to submit to a national background check using fingerprinting and you must list each address for the last five (5) years below.

Notice to Applicant: By signing this form you give consent for the Arkansas State Police and the FBI to release your national criminal history to the Division of Provider Services & Quality Assurance (DPSQA) for employment purposes. Pursuant to Arkansas Code Ann. § 20-38-101 et. seq. The Applicant will receive a letter if they were disqualified advising them of their rights and the process to challenge the results. Prior to the determination of eligibility, the employer may choose to deny any employee unsupervised access to a person to whom the employer provides care.

Challenge Information: Your fingerprints will be used to check the criminal history records of the FBI. You have the opportunity to complete or challenge the accuracy of the information contained in the FBI identification record. The procedure for obtaining a change, correction, or update of an FBI criminal history record are set forth at 28 CFR 16.34. Information regarding this process may be found at https://www.fbi.gov/services/cjis/identity-history-summary-checks and https://www.edo.cjis.gov.

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/biometrics 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: During the processing of this application and for as long thereafter as your fingerprints and associated information/biometrics 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.

Statement of Oath: I state on oath that the representations made herein are true, complete, and correct.

Providing false information on this form is a violation of Arkansas law and is punishable as set forth in Arkansas Code Annotated § 5-53-103.