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**1. Current Legal Name:** List your first, middle, and last name as they are listed on your current Driver's License or other primary photo ID. Accepted government-issued photo ID includes any federal, state, or local government-issued ID, US military ID, US or foreign passport, or federally recognized tribal ID. Write N/A in each field that you do not have a name to enter.

**2. Other Alias Names:** Print all other first, middle, or last names you have used. Other names include nicknames, birth names, maiden names, etc. If you have not used any other first, middle, or last names, you must enter N/A in the appropriate box. Do not leave any of the boxes blank.

**3. Date of Birth:** Print your date of birth listing the month, day, and year (MM/DD/YYYY).

**4. Phone Number:** Phone number where you can be reached Monday through Friday between 8:00 AM to 5:00 PM. By checking the box, you are authorizing BCCU to leave a detailed message.

**5. Email Address:** By providing your email address and checking the consent box, you are giving BCCU consent to send you confidential and sensitive background check information, including a fingerprint rap sheet (if applicable). BCCU will not mail or email when no background information is found (No Record). Contact BCCU if you have questions.

**6. Social Security Number:** You may choose to provide your Social Security Number. Your Social Security Number helps the Background Check Central Unit (BCCU) match your name and date of birth to existing records in our database and may speed up completion of your background check.

**7A. Driver's License or State-Issued ID Number:** Print your Driver's License or state-issued ID number.

**7B. State of Issuance:** The state where your Driver's License or ID was issued.

**8. Residence:** If you have continuously lived in Washington State without living in another state or country for the last three years (36 months), answer NO. If you have lived in any state or country other than Washington State within the last three years (36 months), answer YES.

**9. Mailing Address:** Print your mailing address where BCCU can send you confidential information such as a copy of your background check results.

**10. Street Address:** Print your street address if it is different from your mailing address. If your street address and mailing address are the same, enter SAME.

**11A. Criminal Convictions:** You must check YES or NO. If you check YES, complete Page 2, Section 3, List of Crimes and Pending Charges, of the form by entering the crime name, degree (if any), state, and the conviction date (MM/DD/YYYY). Mark the correct other crime information box or NIA. If the crime was committed outside of Washington State, provide a brief description. If you need to list additional convictions, attach additional copies of Page 2 to the form. Include your name and all the required information listed above.

**11B. Pending Charges:** You must check YES or NO. If you check YES, you must complete Page 2, Section 4, List of Crimes and Pending Charges, of the form by entering the pending charge name, degree (if any), and state. Mark the correct other crime information box or NIA. If the crime was committed outside of Washington State, provide a brief description. If you need to list additional pending charges, attach additional copies of Page 2 to the form. Include your name and all the required information listed above.

**12-14. Self-Disclosure Questions:** Read each question carefully before answering. You must check YES or NO. Question 14: Permanent means the order was issued either following a hearing or by stipulation of the parties.

**15. Signature:** Read the statements above and sign your name as it is listed in Box 1. If you are not 18 years old, a parent or guardian must sign for you.

**16. Signature Date:** Enter the month/day/year (MM/DD/YYYY) you signed Box 15.

Important Information about Answering Self-Disclosure Questions (11A-14): Your answers to self-disclosure questions become part of your background check history and are stored in the DSHS database. Self-disclosures are reported as part of your background check result like any other background check history we receive. It is important that your answers to self-disclosure questions are accurate and consistent. It is strongly recommended that you answer self-disclosure questions the same way each time you complete the Background Check Authorization form unless the question has changed or the previous answer was wrong. It is also recommended that you refer to charging papers, court records, or other official documents and that you list criminal convictions, pending charges, dates, and other information exactly as they are listed in those documents.

Questions about the Background Check Process: Contact the Background Check Central Unit (BCCU) by email at [email protected] or by phone at 360-902-0299.