DFPS Janitor, Security Guard, and Shred Contractors Background Check Request Form (.pdf

Form F-500-4048

Revised December 2019

DFPS JANITOR, SECURITY GUARD, AND SHRED CONTRACTORS

BACKGROUND CHECK REQUEST FORM

Purpose: DFPS policies and FBI Outsourcing Standards require DFPS to perform criminal and abuse, neglect, and exploitation background checks on individuals authorized to have access to DFPS confidential information under a contract or agreement for services. Use this form to authorize DFPS to conduct background checks on DFPS Janitors, Security Guards, and Shred Contractors who require access to DFPS resources, clients, and facilities.

Directions: The entities below complete the following steps:

1. The employer or performing contractor completes Section 1: Contractor Information and Section 2: Contractor Certifications.

2. The employee completes Section 3: Personal Information, Section 4: Previous Places of Residence, and

Section 5: Signature.

3. The employer or performing contractor submits the completed form to DFPS via email at extaccbgc@dfps.state.tx.us.

4. Background Checks staff notify the employer or performing contractor of the person’s clearance when the check is completed, typically in one to two weeks.

SECTION 1 – CONTRACT INFORMATION

Name of the Company/Vendor:

HHSC Contract Manager:

HHSC Contract Number:

Purchase Order Number: Contract Tax ID Number:

Company/Vendor Address:

City: State: Zip Code:

Contact Person to Receive Results of Background Checks (Name and Title)

Email Address to Receive Results:

SECTION 2 - CONTRACTOR CERTIFICATIONS

As the authorized agent of the performing contractor under an agreement with DFPS for

Shredding services

Security services

Janitorial services

I certify (enter subject’s name) is authorized personnel under the terms of the Outsourcing Standard and has a legitimate business need to access DFPS resources, clients, or facilities.

I have verified, by viewing the person's social security card or driver’s license, that the information on this form contains no willful misrepresentation and that the information is true and correct to the best of my knowledge. I understand that DFPS may contact others to seek proof of the information contained here, and that any willful misrepresentation or failure to provide information may be cause for denial or revocation of my contract.

mailto:extaccbgc@dfps.state.tx.us

Signature:

X

Printed Name:

Date:

Title:

Phone:

SECTION 3 - PERSONAL INFORMATION

First Name:

Middle Name:

No Middle Name

Last Name:

Other names or spellings used (married, maiden, alias, etc.) - First, Middle, Last No Other Names

Home Address:

City: State: Zip Code:

County of Residence:

Date of Birth: Phone Number:

Social Security No. (if no SSN, provide alternate document name and ID number)

Driver’s License Number and State:

Gender:

Male

Female

Ethnicity:

Hispanic/Latino

Non-Hispanic/Latino

Race:

White

Black

Asian

American Indian/Alaskan Native

Native Hawaiian/Pacific Islander

SECTION 4 - PREVIOUS PLACES OF RESIDENCE

Have you lived outside the state of Texas in the past two years?

Yes

No

List the complete address with dates of other places you have resided (for a minimum of the past two (2) years – continue on back as needed)

Full Address (include city, state, and zip code):

MM/YYYY - MM/YYYY

Resided:

SECTION 5 - PRIVACY STATEMENT

DFPS values your privacy. For more information, read our Privacy and Security Policy.

SECTION 6 - SIGNATURE

I understand that in performing my assigned job duties, I may have access to or may view documents that contain data or information that is considered confidential under law. I understand that I may not disclose, distribute, or communicate this information unless authorized.

I am aware of the requirements of the FBI Outsourcing Standard and the state and federal laws that apply to my assigned job duties. I understand my responsibilities to follow and maintain DFPS Information Security policies and procedures and to safeguard the confidentiality of DFPS information at all times.

I understand that violating these or other Information Security policies, procedures, or standards may subject me to prosecution under one or more applicable statutes, and I will no longer be allowed to perform my job duties for this contractor.

I understand that background checks are conducted on an annual basis for janitors, security guards, and shred contractors. I authorize DFPS to conduct a criminal history and DFPS abuse and neglect check each year that I have access to DFPS clients and resources.

I declare the information provided on this form is true and correct, and I understand that any misrepresentation or omission may result in my being barred from my job duties with this contractor.

I agree to immediately inform my employer if I am named in allegations, complaints, indictments, or convictions of felony or misdemeanor offenses, or if I am named in allegations of abuse, neglect, or exploitation.

I understand that I have the right to contest the information found in my criminal background checks.

I understand that by signing this Electronic Signature Acknowledgement form, it is equivalent to my handwritten signature and legally binding. Whenever I execute an electronic signature, it has the same validity and meaning as my handwritten signature. I will not, at any time in the future, repudiate the meaning of my electronic signature or claim that my electronic signature is not legally binding. I acknowledge and warrant the truthfulness of the information provided in this document.

Signature:

X

Date Signed:

https://www.dfps.state.tx.us/policies/Website/