Form CBCC "Dfa Criminal Background Check Consent Form for Applicant and Employees" - Arkansas

What Is Form CBCC?

This is a legal form that was released by the Arkansas Department of Finance & Administration - a government authority operating within Arkansas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on April 4, 2017;
  • The latest edition provided by the Arkansas Department of Finance & Administration;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form CBCC by clicking the link below or browse more documents and templates provided by the Arkansas Department of Finance & Administration.

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Download Form CBCC "Dfa Criminal Background Check Consent Form for Applicant and Employees" - Arkansas

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ARKANSAS DEPARTMENT OF FINANCE & ADMINISTRATION
DFA CRIMINAL BACKGROUND CHECK CONSENT FORM FOR APPLICANTS & EMPLOYEES
I understand that if I am an applicant for any position or a current employee within the Arkansas Department of
Finance & Administration (DFA), including any position that authorizes the manufacture or production of REAL ID
driver’s licenses or identification cards or has access to such ability in accordance with Title 49 CFR 1572.103 prior
to an offer of employment or review for continued employment with DFA shall obtain a state and/or federal (FBI)
criminal history check through the Arkansas State Police.
I further understand that the information is for the official use of DFA in connection with its determination of my
suitability for employment.
I consent to any authorized representative of DFA to obtain any information pertaining to my criminal history record
(including but not limited to, any record of arrest or conviction for criminal offenses). I authorize each law enforcement
agency to which this form is presented to release any results, upon request of the authorized requestors as described
above.
Copies of this consent that show my signature are as valid as the original signed by me. This consent is valid until
the termination of my application process, separation of my employment with DFA, or termination of any affiliation
with the DFA, whichever is later.
First - Middle - Last Name (Please Print - Information must match what is on your Driver’s License or State ID Card)
Other Names Used
Personnel Number (current employee)
Male
White/Hispanic
Social Security Number
Race
Sex
Place of Birth (City, State)
Date of Birth
Valid Identifying Document (Driver’s License No., Passport, Birth Certificate, etc.)
Daytime Phone Number and Email
Signature of Applicant/Employee (In Ink)
Date
Signature of Witness
Full Name and Title of Witness (type or print clearly)
TO BE COMPLETED BY HIRING OFFICIAL: (Print or Type)
Position Title:____________________________________________ Position Number:_______________________________
Hiring Official:______________________________________Title:_______________________________________________
Email Address:________________________________________________________________________________________
Bus Area: ______ Office:____________________________Phone:__________________Fax:_________________________
PLEASE CHECK TYPE OF BACKGROUND CHECK (Select One):
AR State Police *Required for ALL DFA Positions
Real ID Access ** ONLY Authorized Positions within State Revenue Offices & Driver Services
CBCC (Rev. 4/4/2017)
ARKANSAS DEPARTMENT OF FINANCE & ADMINISTRATION
DFA CRIMINAL BACKGROUND CHECK CONSENT FORM FOR APPLICANTS & EMPLOYEES
I understand that if I am an applicant for any position or a current employee within the Arkansas Department of
Finance & Administration (DFA), including any position that authorizes the manufacture or production of REAL ID
driver’s licenses or identification cards or has access to such ability in accordance with Title 49 CFR 1572.103 prior
to an offer of employment or review for continued employment with DFA shall obtain a state and/or federal (FBI)
criminal history check through the Arkansas State Police.
I further understand that the information is for the official use of DFA in connection with its determination of my
suitability for employment.
I consent to any authorized representative of DFA to obtain any information pertaining to my criminal history record
(including but not limited to, any record of arrest or conviction for criminal offenses). I authorize each law enforcement
agency to which this form is presented to release any results, upon request of the authorized requestors as described
above.
Copies of this consent that show my signature are as valid as the original signed by me. This consent is valid until
the termination of my application process, separation of my employment with DFA, or termination of any affiliation
with the DFA, whichever is later.
First - Middle - Last Name (Please Print - Information must match what is on your Driver’s License or State ID Card)
Other Names Used
Personnel Number (current employee)
Male
White/Hispanic
Social Security Number
Race
Sex
Place of Birth (City, State)
Date of Birth
Valid Identifying Document (Driver’s License No., Passport, Birth Certificate, etc.)
Daytime Phone Number and Email
Signature of Applicant/Employee (In Ink)
Date
Signature of Witness
Full Name and Title of Witness (type or print clearly)
TO BE COMPLETED BY HIRING OFFICIAL: (Print or Type)
Position Title:____________________________________________ Position Number:_______________________________
Hiring Official:______________________________________Title:_______________________________________________
Email Address:________________________________________________________________________________________
Bus Area: ______ Office:____________________________Phone:__________________Fax:_________________________
PLEASE CHECK TYPE OF BACKGROUND CHECK (Select One):
AR State Police *Required for ALL DFA Positions
Real ID Access ** ONLY Authorized Positions within State Revenue Offices & Driver Services
CBCC (Rev. 4/4/2017)