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Records Check Application
Applicant Information
Registration ID
Job Title/Applicant Role
Contract #/RCCL License #
Last Name
First Name
Middle Name
Maiden Name
Address Line 1
Address Line 2
City
State
Zip
Phone Number
Sex
Race
Date of Birth
Not a valid Date
Place of Birth
Reason for Fingerprinting
I understand and have been informed that an FBI/NCIC and GBI/GCIC background check will be conducted.
I have been
provided written notice
of the Applicants Privacy Rights and the Privacy Act Statement. Title 28 CFR 16.30 through 16.34.
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Signature of Applicant
Date
Not a valid Date
Hiring Agency
I, as the hiring official, have verified that the above-named applicant is a prospective employee of this organization. I understand that before the applicant’s fingerprints are submitted to the Georgia Bureau of Investigation (GBI) and Federal Bureau of Investigation (FBI), the Department of Human Services (DHS) must verify that the applicant is seeking to provide services and/or gain employment with this agency. This is an FBI requirement.
Note: This verification form should be submitted after the applicant has been registered for fingerprinting within the Georgia Applicant Processing Service (GAPS). Applicants will not be released to a fingerprinting site until this form has been received and the registration has been cleared by DHS.
The information contained within this form will be compared to the information provided in the GAPS registration for accuracy. If any discrepancies are found, DHS will communicate with the hiring agency for resolution.
Applicant cannot proceed to a print site until they receive a confirmation email from GAPS.
Employer Name
Name of Hiring Official
Signature of Hiring Official
Telephone
Employer’s Email Address