52-IFB-2400404908-JJC - Attachment J - Background Check Form.pdf

This is a Criminal History Record Check Form (DAC-HR 004) used by the North Carolina Department of Adult Correction for background screening purposes. The form serves as a standardized document to collect personal identification and background information on individuals applying for employment, internship, volunteer, or managerial positions within the department. Section I is completed by a manager or designee and documents the date of request and results of the criminal history check conducted by the DCI (Division of Criminal Information), including indicators for clean records, pending cases, unserved warrants, or disposed charges. Section II is completed by the applicant or employee and requires comprehensive personal information including full name with all previously used last names, date of birth, Social Security number, driver's license information, place of birth, physical descriptors such as height, weight, hair and eye color, and detailed identification of any scars, tattoos, or marks.

The form mandates that applicants provide their current address and, if residing at that location for less than five years, all previous addresses covering a minimum five-year history. Section III is reserved for DCI operator use only and documents the completion of the background check with fields for SID and FBI numbers, the DCI operator's name, and the date the check was completed. The applicant must sign and date the form, certifying that all provided information is true, accurate, and complete to the best of their knowledge. This form is associated with the Enterprise Meat Processing Plant's preventative maintenance contract opportunity at the North Carolina Department of Adult Correction facility in Lillington, North Carolina, indicating that background checks are a requirement for personnel involved in this contract work.