Background_Check_Form.pdf
PDF 1012 KB Posted
- Solicitation number
- 2026-RFP-157
- Issued by
- Pierce County, Washington
About this file
This is a Background Check Form issued by Pierce County Facilities Management in Washington for use in processing security clearances for county facility access. The form is designed to collect applicant information and authorize criminal history investigations required for badge access and entry to Pierce County sites. Applicants must provide complete personal identification details, including name, date of birth, address history, driver's license information, and social security number (last four digits). The form requires applicants to disclose all cities and states where they have resided and to indicate whether they have lived continuously in Washington State for the past five years. The background check process includes multiple verification steps: fingerprint collection, Global Name Inquiry, Washington State Information System (WASIS) and National Crime Information Center (NCIC) III checks, out-of-state checks when applicable, Department of Licensing reviews for each relevant state, LINX and LINX NW database searches, and Interpol checks when warranted. The form designates background levels as either Moderate or PREA CJIS and requires notation of whether applicants need LENEL ACCESS or CJIS AREA authorization.
The form requires applicants to submit a valid driver's license or state identification card and to sign a certification statement acknowledging their understanding that providing false information constitutes grounds for immediate and potentially permanent denial of facility access. Applicants authorize Pierce County Facilities Management and the Pierce County Sheriff's Department to conduct complete criminal background investigations and verify all submitted information. The completed form must be processed through the Pierce County Sheriff's Department's Background Investigation Unit, with results documented as cleared, denied, or not applicable. This background check requirement applies to contractors and service providers, including those bidding on Pierce County service contracts such as the Countywide Window Cleaning Services solicitation, ensuring that individuals with access to county facilities meet established security and safety standards.
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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
Dalton Gamboa - FPM Draft
Dalton Gamboa - FPM Draft
Dalton Gamboa - FPM Draft
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