Fillable Printable Uep Service Code Form V4X

Uep Service Code Form V4X

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Texas Fingerprint Service Code Form

Background Check Waiver

I certify that all information I provided in relation to this criminal history record check is true and

accurate. I authorize the Texas Department of Public Safety (DPS) to access Texas and Federal

criminal history record information that pertains to me and disseminate that information to the

designated Authorized Agency or Qualified Entity with which I am or am seeking to be employed or to

serve as a volunteer, through the DPS Fingerprint-based Applicant Clearinghouse of Texas and as

authorized by Texas Government Code Chapter 411 and any other applicable state or federal statute

or policy.

I authorize the Texas Department of Public Safety to submit my fingerprints and other application

information to the FBI for the purpose of comparing the submitted information to available records in

order to identify other information that may be pertinent to the application. I authorize the FBI to

disclose potentially pertinent information to the DPS during the processing of this application and for

as long hereafter as may be relevant to the activity for which this application is being submitted. I

understand that the FBI may also retain my fingerprints and other applicant information in the FBI’s

permanent collection of fingerprints and related information, where all such data will be subject to

comparisons against other submissions received by the FBI and to further disseminations by the FBI

as may be authorized under the Privacy Act of 1974 (5 USC 552a). I understand my fingerprints will

be searched by and against civil, criminal and latent fingerprints in the Next Generation Identification

(NGI) system. I understand I am entitled to obtain a copy of any criminal history record check and

challenge the accuracy and completeness of the information before a final determination is made by

the Qualified Entity. I also understand the Qualified Entity may deny me access to children, the elderly,

or individuals with disabilities until the criminal history record check is completed. If a need arises to

challenge the FBI record response, you may contact the agency that submitted the information to the

FBI, or you may send a written challenge request to the FBI's Criminal Justice Information Services

(CJIS) Division at FBI CJIS Division, Attention: Correspondence Group, 1000 Custer Hollow Road,

Clarksburg, WV 26306.

Don’t have access to the Internet? You can still schedule an appointment by calling 888.467.2080

Service Code is unique to your hiring/licensing agency. Do not use this code for another purpose.

To schedule your ten-minute fingerprint appointment, simply visit

https://uenroll.identogo.com and enter the following Service Code

Department of Insurance Use Only

Service Name: Dept. of Insurance

11G6QF