Background Check Authorization

Section 1. Required: Applicant Information (All sections completed by the applicant, the person receiving a background check).
The requesting entity will submit the applicant’s information through the online Background Check System (BCS).
1. REQUIRED: LEGAL NAME AS IT IS LISTED ON YOUR DRIVER’S LICENSE OR GOVERNMENT ISSUED PHOTO IDENTIFICATION (ID)
FIRST MIDDLE LAST

2. REQUIRED: OTHER ALIAS FIRST, MIDDLE, AND LAST NAMES YOU HAVE USED
FIRST MIDDLE LAST

3. REQUIRED: DATE OF BIRTH 4. REQUIRED: PHONE NUMBER 5. EMAIL ADDRESS

(MM/DD/YYYY) (INCLUDE AREA CODE)

6. SOCIAL SECURITY NUMBER 7A. REQUIRED: VALID DRIVER’S LICENSE 7B. REQUIRED: ISSUING STATE
OR STATE ID (WRITE NONE IF NONE)

8. REQUIRED: HAVE YOU LIVED IN ANY STATE OR COUNTRY OTHER THAN WASHINGTON STATE WITHIN THE LAST THREE YEARS (36
MONTHS)?
Yes No
9. REQUIRED: MAILING ADDRESS WHERE WE CAN SEND YOU CONFIDENTIAL INFORMATION
STREET APT. NO. CITY STATE ZIP CODE

10. REQUIRED: PHYSICAL ADDRESS WHERE YOU LIVE NOW (WRITE “SAME” IF ADDRESS IS THE SAME AS YOUR MAILING ADDRESS)
STREET APT. NO. CITY STATE ZIP CODE

Section 2. Required: Self-Disclosure Questions for ALL convictions and pending charges from any state or jurisdiction. You
must answer Questions 11A through 14. Attach Page 2 if you have crimes or pending charges. SEE INSTRUCTIONS.

11A. Have you been convicted of any crime? If yes, complete Page 2, Section 3........................................................ Yes No
11B. Do you have charges (pending) against you for any crime? If yes, complete Page 2, Section 4.......................... Yes No
12. Has a court or state agency ever issued you an order or other final notification stating that you have
sexually abused, physically abused, neglected, abandoned, or exploited a child, juvenile, or vulnerable adult? .. Yes No
13. Has a government agency ever denied, terminated, or revoked your contract or license for failing to care
for children, juveniles, or vulnerable adults; or have you ever given up your contract or license because a
government agency was taking action against you for failing to care for children, juveniles, or vulnerable
adults? ................................................................................................................................................................... Yes No
14. Has a court ever entered any of the following orders against you for abuse, sexual abuse, neglect,
abandonment, domestic violence, exploitation, or financial exploitation of a vulnerable adult, juvenile, or child? . Yes No
 Permanent vulnerable adult protection order / restraining order, either active or expired, under RCW 74.34.
 Sexual assault protection order under RCW 7.90.
 Permanent civil anti-harassment protection order, either active or expired, under RCW 10.14.

I am the person named above. If I do not tell the whole truth on this form, I understand I can be charged with perjury and I may not
be allowed to work with vulnerable adults, juveniles, or children. I understand and agree my signature in the box below means:
 I give DSHS permission to check my background with any governmental entity and law enforcement agency.
 My background check result may include prior self-disclosure information and fingerprint results that are contained in the
DSHS Background Check System and that this information will be reported as allowed by federal or state law.
 If a final finding is identified, DSHS will report only my name and that a final finding was identified on the background check result.
 DSHS will give my background check result to the persons or entities requesting my background check and those persons or
entities may release my background check results to other persons or entities when the law authorizes or requires DSHS to
do so. Fingerprint rap sheets are provided if allowed by federal or state law.
15. REQUIRED: SIGNATURE. YOUR PARENT OR GUARDIAN’S SIGNATURE IF YOU ARE UNDER 18. 16. REQUIRED: TODAY’S
DATE (MM/DD/YYYY)

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DSHS 09-653 (REV. 06/2018)
 Background Check Authorization
List of Crimes and Pending Charges
This page MUST be attached to Page One of the Background Check Authorization form if 11A or 11B are marked “Yes.”
Important information about answering self-disclosure questions: Your answers to self-disclosure questions become part of
your background check history and are stored in the DSHS database. It is 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.
REQUIRED: PRINT YOUR NAME AS IT IS LISTED ON YOUR DRIVER’S LICENSE OR GOVERNMENT ISSUED PHOTO ID

FIRST: MIDDLE: LAST:

REQUIRED: DATE OF BIRTH (MM/DD/YYYY)

Section 3. Question 11A. If you check YES, you must enter the crime name, degree (if any), state, conviction date, and crime
information.
1. CRIME NAME DEGREE (IF ANY) STATE CONVICTION DATE
(MM/DD/YYYY)

Other crime information: Attempted Conspiracy Domestic Violence Solicitation With Sexual Motivation N/A
DESCRIPTION OF CRIME (REQUIRED WHEN CRIME IS COMMITTED OR CONVICTED OUTSIDE OF WASHINGTON STATE)

2. CRIME NAME DEGREE (IF ANY) STATE CONVICTION DATE

(MM/DD/YYYY)

Other crime information: Attempted Conspiracy Domestic Violence Solicitation With Sexual Motivation N/A
DESCRIPTION OF CRIME (REQUIRED WHEN CRIME IS COMMITTED OR CONVICTED OUTSIDE OF WASHINGTON STATE)

3. CRIME NAME DEGREE (IF ANY) STATE CONVICTION DATE

(MM/DD/YYYY)

Other crime information: Attempted Conspiracy Domestic Violence Solicitation With Sexual Motivation N/A
DESCRIPTION OF CRIME (REQUIRED WHEN CRIME IS COMMITTED OR CONVICTED OUTSIDE OF WASHINGTON STATE)

Section 4. Question 11B. If you check YES, you must enter the PENDING charge name, degree (if any), state, and crime
information.
1. CRIME NAME DEGREE (IF ANY) STATE

Other crime information: Attempted Conspiracy Domestic Violence Solicitation With Sexual Motivation N/A
DESCRIPTION OF CRIME (REQUIRED WHEN CRIME IS COMMITTED OR CONVICTED OUTSIDE OF WASHINGTON STATE)

2. CRIME NAME DEGREE (IF ANY) STATE CONVICTION DATE

(MM/DD/YYYY)

Other crime information: Attempted Conspiracy Domestic Violence Solicitation With Sexual Motivation N/A
DESCRIPTION OF CRIME (REQUIRED WHEN CRIME IS COMMITTED OR CONVICTED OUTSIDE OF WASHINGTON STATE)

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DSHS 09-653 (REV. 06/2018)
 Instructions for Completing the Background Check Authorization form, DSHS 09-653
These instructions provide general directions for completing the Background Check Authorization form. This form is used by
multiple DSHS programs to meet varying background check needs. The DSHS oversight program requiring the background check
may have additional instructions that you must follow.
Important: The requesting entity cannot submit your background check unless ALL required boxes are complete. Required boxes
have the word “REQUIRED:” next to the box number. The requesting entity will submit your completed background check through
the online Background Check System (BCS).
This form is to be completed by the applicant, the person whose background DSHS is checking.
BOX NO. INSTRUCTIONS
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 Print your date of birth listing the month, day, and year (MM/DD/YYYY).
4 Enter the daytime phone number, including area code, where you can be reached weekdays 8 AM to 5 PM.
5 Provide an email address where you can be reached.
6 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 Enter your Driver’s License or state-issued ID number.
7B The state where your Driver’s License or ID was issued.
8 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 Enter your mailing address where BCCU can send you confidential information such as a copy of your background
check results.
10 Enter your street address if it is different than your mailing address. If you street address and mailing address are the
same, enter SAME.
11A 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 N/A. 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 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 N/A. 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 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 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 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
bccuinquiry@dshs.wa.gov or phone at 360-902-0299.

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