Form 0505RCCD-019 "Volunteer and Employee Criminal History System (Vechs) Applicant Waiver Agreement and Statement" - Nevada

What Is Form 0505RCCD-019?

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 June 1, 2020;
  • 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-019 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-019 "Volunteer and Employee Criminal History System (Vechs) Applicant Waiver Agreement and Statement" - Nevada

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Records, Communications and Compliance Division
333 West Nye Lane, Suite 100
Carson City, Nevada 89706
Telephone (775) 684-6200 ~ Fax (775) 687-3290
www.rccd.nv.gov
VOLUNTEER and EMPLOYEE CRIMINAL HISTORY SYSTEM (VECHS)
APPLICANT WAIVER AGREEMENT and STATEMENT
For criminal history record information pursuant to the National Child Protection Act of 1993, as amended by the Volunteer for Children Act.
Pursuant to the National Child Protection Act of 1993 (NCPA), as amended by the Volunteers for Children Act (VCA),
this form must be completed and signed by every current or prospective applicant, employee, volunteer, and
contractor/vendor, for whom criminal history records are requested by a qualified entity under these laws.
I hereby authorize (enter name of Qualified Entity)
to submit a set of my fingerprints to the Nevada Department of Public Safety Records (DPS) - Records, Communication
and Compliance Division (RCCD) for the purpose of accessing and reviewing state and national criminal history records
that may pertain to me. I understand that I would be able to receive any national criminal history record that may pertain
to me directly from the Federal Bureau of Investigation (FBI) and pursuant to Title 28, Code of Federal Regulations
(CFR), Sections 16.30-16.34, I could then freely disclose any such information to whomever I chose. By signing this
Waiver Agreement, it is my intent to authorize the dissemination of any national criminal history record that may pertain
to me to the Qualified Entity with which I am or am seeking to be employed or to serve as a volunteer.
I understand that, until the criminal history background check is completed, the Qualified Entity may choose to deny me
unsupervised access to children, the elderly, or individuals with disabilities. I further understand that, if Qualified Entity
policy permits, the Qualified Entity may provide me a copy of the criminal history background report, if any, received
on me and that I am entitled to challenge the accuracy and completeness of any information contained in any such
report. I may obtain a prompt determination as to the validity of my challenge before a final decision is made.
I am a current or prospective (check one): Applicant
Employee
Volunteer
Contractor/Vendor
PLEASE PRINT THE FOLLOWING INFORMATION:
First Name:
Middle Name:
Last Name:
Date of Birth:
Complete Mailing Address:
As listed on Identification document.
I have not (or)
I have been convicted of/am under pending indictment for the following crimes. You are
required to provide dates, locations/jurisdictions, circumstances and outcome of each conviction and/or pending
indictment. Attach a separate sheet if additional space is needed.
Applicant Signature:
Date:
To be completed by Qualified Entity Authorized Personnel:
Print Name:
Signature:
Date:
0505RCCD-019(06/2020 rev)
NOTE: This document must be retained by the Qualified Entity for audit purposes.
Records, Communications and Compliance Division
333 West Nye Lane, Suite 100
Carson City, Nevada 89706
Telephone (775) 684-6200 ~ Fax (775) 687-3290
www.rccd.nv.gov
VOLUNTEER and EMPLOYEE CRIMINAL HISTORY SYSTEM (VECHS)
APPLICANT WAIVER AGREEMENT and STATEMENT
For criminal history record information pursuant to the National Child Protection Act of 1993, as amended by the Volunteer for Children Act.
Pursuant to the National Child Protection Act of 1993 (NCPA), as amended by the Volunteers for Children Act (VCA),
this form must be completed and signed by every current or prospective applicant, employee, volunteer, and
contractor/vendor, for whom criminal history records are requested by a qualified entity under these laws.
I hereby authorize (enter name of Qualified Entity)
to submit a set of my fingerprints to the Nevada Department of Public Safety Records (DPS) - Records, Communication
and Compliance Division (RCCD) for the purpose of accessing and reviewing state and national criminal history records
that may pertain to me. I understand that I would be able to receive any national criminal history record that may pertain
to me directly from the Federal Bureau of Investigation (FBI) and pursuant to Title 28, Code of Federal Regulations
(CFR), Sections 16.30-16.34, I could then freely disclose any such information to whomever I chose. By signing this
Waiver Agreement, it is my intent to authorize the dissemination of any national criminal history record that may pertain
to me to the Qualified Entity with which I am or am seeking to be employed or to serve as a volunteer.
I understand that, until the criminal history background check is completed, the Qualified Entity may choose to deny me
unsupervised access to children, the elderly, or individuals with disabilities. I further understand that, if Qualified Entity
policy permits, the Qualified Entity may provide me a copy of the criminal history background report, if any, received
on me and that I am entitled to challenge the accuracy and completeness of any information contained in any such
report. I may obtain a prompt determination as to the validity of my challenge before a final decision is made.
I am a current or prospective (check one): Applicant
Employee
Volunteer
Contractor/Vendor
PLEASE PRINT THE FOLLOWING INFORMATION:
First Name:
Middle Name:
Last Name:
Date of Birth:
Complete Mailing Address:
As listed on Identification document.
I have not (or)
I have been convicted of/am under pending indictment for the following crimes. You are
required to provide dates, locations/jurisdictions, circumstances and outcome of each conviction and/or pending
indictment. Attach a separate sheet if additional space is needed.
Applicant Signature:
Date:
To be completed by Qualified Entity Authorized Personnel:
Print Name:
Signature:
Date:
0505RCCD-019(06/2020 rev)
NOTE: This document must be retained by the Qualified Entity for audit purposes.