Sample Form Template
For use by Michigan criminal justice agencies when
determining eligibility for access to criminal justice information.
Review by your legal department is recommended.
BACKGROUND AUTHORIZATION REQUEST FOR
CRIMINAL JUSTICE PERSONNEL, CONTRACTORS, AND VENDORS
Place individual agency name and contact information here.
I. Requestor Information
Requestor (Agency Contact/Hiring Authority)
Date
Agency
Division
Email Address
II. Applicant Information
Position
Type of Employment
Temporary Employee Permanent Employee Contractor/Vendor
Name of Applicant (Last, First, Middle)
Home Address
City
State
ZIP Code
Social Security Number (Optional)
Date of Birth
Driver’s License Number
Sex
Male Female
Race
American Indian/Alaskan Native Asian/Pacific Islander Black (African American)
Hispanic White Other
III. Authorization
By signing this authorization, the applicant grants permission to (Agency Name) to conduct a fingerprint-based
background check for the express purpose of determining whether the applicant is eligible to access criminal
justice information and/or physically secure facilities.
I understand the personal information and fingerprints submitted are used to search against criminal
identification records from both the state of Michigan and the Federal Bureau of Investigation (FBI). I hereby
authorize the release of any records to the agency listed above. I further understand the information and
fingerprints may be retained, as permitted by MCL 28.248 and the Privacy Act of 1974, 5 USC § 552a, for
routine uses beyond the principal purpose listed above. Routine uses include, but are not limited to,
disclosures to governmental authorities responsible for civil or criminal law enforcement, counterintelligence,
national security, or public safety.
Applicant Signature: ____________________________________________________________ Date: ________________
28 CFR §16.34 - Procedure to obtain change, correction, or updating of identification record:
If any information is found that the applicant believes is incorrect or incomplete in any respect and wishes changes, corrections, or
updating of the alleged deficiency, he/she should make application directly to the agency that contributed the questioned
information. The subject of a record may also direct his/her challenge as to the accuracy or completeness of any entry on his/her
record to the FBI, Criminal Justice Information Services (CJIS) Division, ATTN: SCU, Mod. D2, 1000 Custer Hollow Road,
Clarksburg, West Virginia, 26306. The FBI will then forward the challenge to the agency that submitted the data requesting they
verify or correct the challenged entry. Upon receipt of an official communication directly from the agency that contributed the
original information, the FBI CJIS Division will make any changes necessary in accordance with the information supplied by that
agency.
