FOR OFFICE USE ONLY

Date Received:
Action Log:
Cleared: HIT:
SELF-DECLARATION AND FBI Reject 1: FBI Reject 2:
Exemption: Denied:
AUTHORIZATION FOR
CRIMINAL HISTORY CHECK

Last Name First Name

List Former Name(s) (Maiden, AKA, etc.) List Former Name(s) (Maiden, AKA, etc.)

List Former Name(s) (Maiden, AKA, etc.) List Former Name(s) (Maiden, AKA, etc.)

Street Address City State Zip

Daytime Telephone Number Date of Birth Place of Birth - City and State

Social Security Number Driver's License Number Sex Race

Height Weight Hair Color Eye Color E-mail Address

I am applying as a DV Evaluator in the .

If you answer YES to any one of questions 1 through 5, or NO to question 6 below, you will be asked to
provide an explanation of each item. Please include the date, location, crime/incident, and action.

1. Do you have an arrest record in this or any other state? Yes No

2. Have you ever pled guilty or been convicted of a crime as an adult or
juvenile? Check YES, even if the conviction was sealed or the judgement Yes No
was withheld. (include traffic crimes, such as DUI, reckless driving, or
driving without privileges, but do not include traffic infractions such as excessive speed.)
3. Do you have criminal charges or warrants pending against you or are you
on probation or parole in this state or any other state? Yes No

4. Have you ever had a valid child or adult protection action filed against you? Yes No

5. Has your driver's license ever been suspended or revoked? Yes No

6. Do you have a valid driver's license today? Yes No

Clear Form
 Authorization to
Investigate
I hereby authorize the Idaho Supreme Court (Court) to conduct a criminal history and background
check on me. I understand that my fingerprints will be sent to the FBI for processing and
I authorize the Court to gather information from any city, county, state, and/or federal law
enforcement agencies, the Idaho Department of Health and Welfare, the Idaho Sex Offender
Registry, and any other source deemed necessary by the Court. I release the Court from any and
all liability and expense associated with this investigation.

Self-Declaration:

I swear/affirm that the information on this form is true and accurate to the best of my knowledge.
My signature reflects my understanding that I am signing this document under oath under penalty
of perjury. I understand that any fraud, misrepresentation, or omission in my answers may result
in my disqualification or dismissal.

Date Applicant's Signature

Notary

State of )
) ss.
County of )

Subscribed and sworn to before me this day of , 20 .

Signature
Residing at:
My commission expires:
 The Administrative Office of the Idaho Supreme Court
208-947-7416
PO Box 83720 swendt@idcourts.net
Boise, ID 83720-0101

I.C.A.R. 47 and I.C.A.R. 75

Criminal Justice Employment - Domestic Violence Evaluator
 Idaho State Police
Bureau of Criminal Identification

NONCRIMINAL JUSTICE APPLICANT PRIVACY STATEMENT

As an applicant who is the subject of a national fingerprint-based criminal history record check for a non-criminal
justice purpose you have certain rights which are discussed below.

This serves as notification from the Idaho Supreme Court that your fingerprints will be used to check the criminal
history records of the State of Idaho and the FBI and that those records will be used solely for the purpose requested and
may not be disseminated outside the receiving department, related agency or other authorized entity. The collection of
applicant fingerprints in Idaho is authorized by Idaho Code §67-3008.

• If you have a criminal history record, the officials 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 info1mation in the record.
• Procedures for obtaining a change, correction, or updating of your criminal history record are set forth at Title 28, Code of
Federal Regulations (CFR), Section 16.34.
• If you have a criminal history record, you should be afforded a reasonable amount of time to correct or complete the record,
or decline to do so, before being denied the job, license, or other benefit based on information in the criminal history record.
• Disclosure of your Social Security number is voluntary and is solicited pursuant to the Federal Privacy Act and Idaho Code
§67-3012 to aid the processing of an interstate background check request for noncriminal justice purposes allowed by federal
statute, federal executive order or a state statute that has been approved by the attorney general.

The fingerprints and information reported from this request may be disclosed pursuant to your consent, and may also be
disclosed by the FBI without your consent as permitted by the Federal Privacy Act of 1974 (5 U SC 552a(h)). Routine
uses include, but are not limited to, disclosures to appropriate governmental authorities responsible for civil or criminal
law enforcement, counterintelligence, national security or public safety matters to which the information may be relevant;
to State and local governmental agencies and nongovernmental entities or application processing as authorized by Federal
and State legislation, executive order, or regulation, including employment, security, licensing, and adoption checks.
Depending on the nature of your application, other authorities may include numerous Federal or State statutes pursuant to
Public Law 92-544 or other authorized authorities.

According to Idaho state law and if agency policy permits, you may be provided a copy of your FBI criminal history
record for review and possible challenge upon submission of a written request. If agency policy does not permit it to
provide you a copy of the record, you may obtain a copy of the record by submitting fingerprints and a fee to the FBI.
Information regarding this process may be obtained at http://www.fbi.gov/about-us/cjis/background-checks.

If you decide to challenge the accuracy or completeness of your FBI criminal history record, you should send your
challenge to the agency that contributed the questioned information to the FBI. Alternatively, you may send your
challenge directly to the FBI at the same website address as provided above. The FBI will then forward your challenge to
the agency that contributed the questioned information and request the agency to verify or correct the challenged entry.
Upon receipt of an official communication from that agency, the FBI will make any necessary changes/corrections to your
record in accordance with the information supplied by that agency. (See 28 CFR 16.30-16.34)
If a change, correction or update needs to be made to an Idaho criminal history record, that process information is
available on the Idaho State Police website.
http://www.isp.idaho.gov/identification/crime history/FreguentlyAskedQue stions-CriminalRepositorv.html.
Your signature below acknowledges this agency has informed you of your privacy rights for fingerprint-based background check requests used by the
agency tor non-criminal justice purposes

I do do not want a copy of the Privacy Act Statement.

Signature of Applicant Date

700 S. Stratford Dr., Ste. 120 Dec-11

Meridian,ID 83642