Form 0505RCCD-012 "Non-criminal Justice (Civil) Application" - Nevada

What Is Form 0505RCCD-012?

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

Form Details:

  • Released on July 1, 2017;
  • The latest edition provided by the Nevada Department of Public Safety;
  • 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 printable version of Form 0505RCCD-012 by clicking the link below or browse more documents and templates provided by the Nevada Department of Public Safety.

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Download Form 0505RCCD-012 "Non-criminal Justice (Civil) Application" - Nevada

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Records, Communications and Compliance Division
333 West Nye Lane, Suite 100
Carson City, Nevada 89706
Telephone (775) 684-6262 – Fax (775) 687-3288
www.rccd.nv.gov
NON-CRIMINAL JUSTICE (Civil) APPLICATION
Nevada authorizes governmental and certain organizations to conduct fingerprint-based background checks to help
determine the suitability of a person applying for a license, employment, or a volunteer position.
Before an agency can ask an applicant to go get fingerprinted an agency must submit an application and apply with the
Department of Public Safety – Records, Communications and Compliance Division (RCCD) to become an authorized
recipient under a Nevada Revised Statute (NRS), Federal authority, and/or local or city ordinance.
Both State and Federal Criminal History Record Information are subject to laws, rules and regulations governing
its access, use, handling and dissemination.
A User Agreement will be generated from information provided in the attached application and presented to the
user/receiving agency for signature within 6 months of establishing the account. The User Agreement will be
presented during the initial audit and training conducted by RCCD NCJIS Compliance Unit staff.
RCCD retains the right to suspend your agency’s account in the event the User Agreement is not completely executed
in a timely manner.
DOCUMENTATION FOR ACCESS:
Application must be completed in full with the below required documents at the time of submission. Incomplete
applications will not be processed.
A copy of your current Nevada State Business License issued by the Nevada Secretary of State.
Note: If your agency is a non-profit submit your Charter Certificate issued by the Nevada Secretary of State.
If you need to obtain a copy or apply for a Nevada State Business License or Certificate, please visit www.nvsos.gov.
A copy of your Federal Employer Identification Number (FEIN) issued by the Internal Revenue Services (IRS). If
you do not have this, please visit
www.irs.gov
for assistance. Note: Excludes sole proprietorships that are using
social security numbers.
Federal and Governmental agencies only need to submit a completed application.
Applicable ONLY if applying under NRS 449: A copy of your license issued by the Department of Health and
Human Services, Division of Public and Behavioral Health, Health Care Quality and Compliance Unit (HCQC).
Include in the submittal of your application a copy of the Nevada Revised Statute, Local Ordinance or Federal authority as
it applies to your business and as indicated on page 3 of this application—ONLY ONE WILL APPLY:
Nevada Revised Statute(s)
Local Ordinance
Federal authority
Please return application, completed in its entirety, to the following:
Nevada Department of Public Safety
Records, Communications and Compliance Division
Attn: NCJIS Compliance Unit (NCU)
333 West Nye Lane, Suite 100
Carson City, NV 89701
(775) 684-6245 or (775) 684-6260
0505RCCD-012(07/2017rev)
Non-Criminal (Civil) Application
Page 1 of 4
Records, Communications and Compliance Division
333 West Nye Lane, Suite 100
Carson City, Nevada 89706
Telephone (775) 684-6262 – Fax (775) 687-3288
www.rccd.nv.gov
NON-CRIMINAL JUSTICE (Civil) APPLICATION
Nevada authorizes governmental and certain organizations to conduct fingerprint-based background checks to help
determine the suitability of a person applying for a license, employment, or a volunteer position.
Before an agency can ask an applicant to go get fingerprinted an agency must submit an application and apply with the
Department of Public Safety – Records, Communications and Compliance Division (RCCD) to become an authorized
recipient under a Nevada Revised Statute (NRS), Federal authority, and/or local or city ordinance.
Both State and Federal Criminal History Record Information are subject to laws, rules and regulations governing
its access, use, handling and dissemination.
A User Agreement will be generated from information provided in the attached application and presented to the
user/receiving agency for signature within 6 months of establishing the account. The User Agreement will be
presented during the initial audit and training conducted by RCCD NCJIS Compliance Unit staff.
RCCD retains the right to suspend your agency’s account in the event the User Agreement is not completely executed
in a timely manner.
DOCUMENTATION FOR ACCESS:
Application must be completed in full with the below required documents at the time of submission. Incomplete
applications will not be processed.
A copy of your current Nevada State Business License issued by the Nevada Secretary of State.
Note: If your agency is a non-profit submit your Charter Certificate issued by the Nevada Secretary of State.
If you need to obtain a copy or apply for a Nevada State Business License or Certificate, please visit www.nvsos.gov.
A copy of your Federal Employer Identification Number (FEIN) issued by the Internal Revenue Services (IRS). If
you do not have this, please visit
www.irs.gov
for assistance. Note: Excludes sole proprietorships that are using
social security numbers.
Federal and Governmental agencies only need to submit a completed application.
Applicable ONLY if applying under NRS 449: A copy of your license issued by the Department of Health and
Human Services, Division of Public and Behavioral Health, Health Care Quality and Compliance Unit (HCQC).
Include in the submittal of your application a copy of the Nevada Revised Statute, Local Ordinance or Federal authority as
it applies to your business and as indicated on page 3 of this application—ONLY ONE WILL APPLY:
Nevada Revised Statute(s)
Local Ordinance
Federal authority
Please return application, completed in its entirety, to the following:
Nevada Department of Public Safety
Records, Communications and Compliance Division
Attn: NCJIS Compliance Unit (NCU)
333 West Nye Lane, Suite 100
Carson City, NV 89701
(775) 684-6245 or (775) 684-6260
0505RCCD-012(07/2017rev)
Non-Criminal (Civil) Application
Page 1 of 4
Records, Communications and Compliance Division
333 West Nye Lane, Suite 100
Carson City, Nevada 89706
Telephone (775) 684-6262 – Fax (775) 687-3288
www.rccd.nv.gov
NON-CRIMINAL JUSTICE (CIVIL) APPLICATION
New Business
Change of Ownership
This business is:
Corporation
S
ole Proprietorship
Government Agency
LLC/Partnership
Agency Name
Federal Tax ID/Social Security Number
Please provide the names of all regulatory or auditing agencies:
Billing Information
Physical Address:
City, State, Zip Code:
Billing Address:
City, State, Zip Code:
Contact Information
Primary Contact Name and Title (printed)
Telephone Number
Email Address
Fax Number
Secondary Contact Name and Title (printed)
Telephone Number
Email Address
Fax Number
Alternate Contact Name and Title (printed)
Telephone Number
Email Address
Fax Number
Terms: Statements will be mailed each month. In order to maintain a current account, the balance in full must be paid within 10 days of
receipt. If a credit limit is granted for this application, the account may be suspended if the credit limit is exceeded or if the account is not
current. If an account is suspended, services will not be provided until the account terms are satisfied. Any change to organization
information including address must be reported within 10 business days.
(Initial Here)
**There will be a $25.00 fee assessed on ALL returned checks/e-checks.**
For use by RCCD Fiscal Staff Only
Account Number:
PEND 3
Date:
Assigned By:
PEND 4
Date:
Date:
0505RCCD-012(07/2017rev)
Non-Criminal (Civil) Application
Page 2 of 4
Records, Communications and Compliance Division
333 West Nye Lane, Suite 100
Carson City, Nevada 89706
Telephone (775) 684-6262 – Fax (775) 687-3288
www.rccd.nv.gov
Response Information and Liaison
(Where the CHRI result(s) of the background investigation will be mailed and maintained.)
Physical Address:
City, State, Zip Code:
Mailing Address:
City, State, Zip Code:
Contact Information
Primary Contact Name and Title (printed)
Telephone Number
(required)
Email Address
Fax Number
Secondary Contact Name and Title (printed)
Telephone Number
(optional)
Email Address
Fax Number
Alternate Contact Name and Title (printed)
Telephone Number
(optional)
Email Address
Fax Number
Authorized Use - Check all that apply:
Authority
Type of Investigation:
List and attach a copy of NRS,
Local or City Ordinance that pertains to your Agency.
Employment
Licensing/Work card
The Department of Public Safety, Records, Communications and Compliance Division is not authorized to
provide legal advice. If you do not know what statutory authority allows you to receive Criminal History
and/or Personal Identifying Information, please seek direction from your governing body or legal counsel.
I, the undersigned, have the authority and am the responsible party to apply for an account on behalf of the agency listed above.
I agree to the terms on page 2 and I understand that any credit limit associated with this account is at the discretion of the
Department of Public Safety, Records, Communications and Compliance Division.
Signature
Printed Name
Date
Criminal History Record Information and the information derived therefrom
SHALL NOT be disseminated outside the State of Nevada or receiving agency.
For use by RCCD NCU Staff Only:
Approved
Denied – Reason for Denial:
Signature:
Date:
0505RCCD-012(07/2017rev)
Non-Criminal (Civil) Application
Page 3 of 4
Records, Communications and Compliance Division
333 West Nye Lane, Suite 100
Carson City, Nevada 89706
Telephone (775) 684-6262 – Fax (775) 687-3288
www.rccd.nv.gov
Criminal History Record Information and the information derived therefrom SHALL NOT
be disseminated outside the State of Nevada or receiving agency.
Additional Information:
Please describe briefly what services your company/organization provides:
Provide the name and physical address where Criminal History Information will be maintained for auditing purposes?
Provide the names and titles of the employees who will have access to the Criminal History Information:
Name
Title
Will another agency handle Human Resources functions for your agency?
YES
NO
If yes, provide the name of the person/business:
What functions will they be performing for your agency?
(Example: reviewing criminal history, accounts payable, accounts receivable, etc.)
0505RCCD-012(07/2017rev)
Non-Criminal (Civil) Application
Page 4 of 4
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