Background_Check_Form.pdf
PDF 2 MB Posted
- Attached to
- Annex EV Chargers
- Solicitation number
- 2026-MPW-162
- Issued by
- Pierce County, Washington
About this file
This is a Background Check Form issued by Pierce County Facilities Management in Tacoma, Washington, used to process criminal history investigations and facility access authorization for county contractors and employees. The form applies to the Annex EV Chargers project located at Pierce County Annex, 2401 S 35th Street, Tacoma, Washington 98409, which involves civil work including asphalt demolition, electrical conduit trenching, and repaving; electrical work including installation of light poles, cameras, electrical and communication conduit; and other work including EV signage and pavement markings. The background check process includes fingerprint analysis, global name inquiries, Washington State Information System (WASIS) and National Crime Information Center (NCIC) checks, state-specific Department of Labor reviews, LINX database searches, and Interpol checks when applicable, with clearance, denial, or not applicable determinations documented by completed initial unit dates.
The form requires applicants to provide comprehensive personal information including legal and alias names, contact details, physical descriptions, driver's license information, Social Security number (last four digits), employment details, and residential history for the past five years. Applicants must authorize Pierce County Facilities Management and the Sheriff's Department to conduct criminal history investigations and verify all submitted information, with false information constituting grounds for immediate and permanent denial of badge or facility access. A valid driver's license or state ID card must be attached to process the request. The background investigation determines whether individuals qualify for facility access based on background level classifications including Moderate, PREA (Prison Rape Elimination Act), and CJIS (Criminal Justice Information Services) designations, as well as LENEL system access requirements.
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Text version
Pierce County Facilities Management
930 Tacoma Ave S
Basement Room B44
Tacoma WA 98402
Office (253)798-7301
Department of Facilities Management
Employer (Completed by Applicant)
Requestor (Completed by Department Security Coordinator)
Sheriff’s Department (Completed when applicable by Sheriff's Department Background Investigation Unit)
Background Level
(For use by PCFM Security Date: _____________
Moderate PREA
CJIS
Pierce County Department: _____________________________________________________________________________________
County Requestor/Project Manager: ____________________________________________________
Project/Contract Name: ______________________________ Location of Project/Contract: _________________________________
Requires LENEL ACCESS: YES NO CJIS AREA: YES NO
Applicant Information (Completed by Applicant)
Last Name: ________________________________ First Name: ____________________ MI: ___
Maiden Name: _____________________________ Email Address: _________________________________________ Other Names Used:
Last Name: ________________________________ First Name: ____________________
Last Name: ________________________________ First Name: ____________________
Home Address:_____________________________ City: _______________ State:______
MI: ____
MI: ____
Zip Code: ______________
DOB: ____\ ____ \ ______ Place of Birth (City, St, Country): ____________________________________________________
Race: _________ Sex:__________ Height: _______ Weight: _____ Eye Color: __________ Phone Number:___________________
Alien Registration #: ________________________________________ Social Security#: (Last Four)
Drivers License #: __________________________ State License is Registered: __________________________________________
YESHave you lived in Washington State Continuously over the past 5 years? NO
List all Cities and States you have lived in: _________________________________________________________________________
Company Name: ____________________________________ Employer Phone Number: ___________________________________
Job Title: __________________________________________ Reason for Access: _________________________________________
Completed Initial Unit # Date Cleared/ Denied/NA Fingerprints
Global Name Inquiry (All)
WASIS / NCIC III
Out of State Check (If Applicable)
DOL (Each State)
LINX
LINX NW
Interpol (If Applicable
Review of NCIC Finger Prints Check
Recommendation: Cleared Denied
**Please Attach a Copy of the Applicant’s Valid Drivers License OR State ID Card to Process this Request**
Mail or Deliver Processed and Completed form to:
Background Certification: Because Pierce County Facilities Management strives to provide a Safe and Secure Environment, I understand that Pierce County Facilities Management will order a criminal history check, and I authorize this investigation.
• I certify that all of the information provided on this application is true and complete.
• I understand providing false information is grounds for immediate and potentially permanent denial of a badge/access to County sites.
• I authorize Pierce County Facilities Management / Pierce County Sheriff's Department to investigate and verify any and all information I have submitted.
Signature: _______________________________________________ Date: __________
Authorization (Completed by Applicant)
Revised 01/28/2025
File details come from the government source that posted it. Updated .