ESBD_442693_1754426933592_Exhibit_G2_DFPS Janitor, Security Guard Background.pdf

Form F-500-4048 Revised May 2021

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 people authorized under a contract or agreement for services to access DFPS confidential information. 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 contractor completes Section 3: Subject of the Background Check, Section 4: Previous Places of Residence, Section 5: Fingerprint Check (for Shred contractors and anyone who has resided outside Texas in the past two years), and Section 7: Signature.

3. The employer or performing contractor submits the completed form to DFPS via email at extaccbgc@dfps.texas.gov.

4. Background Checks staff notifies 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 or vendor:

HHSC contract manager:

HHSC contract number: Purchase order number: Contract tax ID number:

Company or vendor address: City: State: ZIP code:

Contact person to receive results of background checks (name and title):

Email address to receive results:

mailto:extaccbgc@dfps.texas.gov

Form F-500-4048 Revised May 2021

SECTION 2 CONTRACTOR CERTIFICATIONS

As the authorized agent of the performing contractor u nder an agreement with DFPS for:

Shredding services Security services Janitorial services

I c ertify _____________________________(enter subject’s n ame) is a uthorized personnel under the terms o f the outsourcing standard and has a legitimate business need to acce ss DFPS resources, clients, or f acilities.

I have verified, by viewing the person's Social Security card or d river lice nse, that the information on this form contains no w illful misrepresentation and that the information is true and correct to th e best of my knowledge. I understand that DFPS may contact others to se ek proof of the information contained here, and that any willful misrepresentation or f ailure to p rovide information may be cause for d enial or r evocation of my contract.

Signature:

X Printed name: Date:

Title: Phone:

SECTION 3 SUBJECT OF THE BACKGROUND CHECK

Please enter N/A for items that are not applicable.

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 number (If no SSN, provide ID number from alternate document and name of the document.)

Driver license number and state:

Gender:

Male Female

Ethnicity:

Hispanic or Latino Not Hispanic or Latino

Race:

White Black Asian American Indian or Alaska Native Native Hawaiian or Pacific Islander

Revised May 2021

SECTION 4 - PREVIOUS PLACES OF RESIDENCE

Have you lived outside Texas in the past two years?

Yes No

List the complete addresses of other places you have lived and the dates (month and year) you lived there.

Include information for a minimum of the past two (2) years. Continue on the back if needed.

Full address (include city, state, and ZIP code):

Full address (include city, state, and ZIP code):

Full address (include city, state, and ZIP code):

Full address (include city, state, and ZIP code):

From (MM/YYYY):

From (MM/YYYY):

From (MM/YYYY):

From (MM/YYYY):

To (MM/YYYY):

To (MM/YYYY):

To (MM/YYYY):

To (MM/YYYY):

SECTION 5 – FINGERPRINT CHECK

To be completed by all shred contractors and anyone who an swered “Yes” in Section 4.

All shred contractors and anyone who answered “Yes” to the question in Section 4 require an FBI fingerprint background check and must provide either an email address or phone number in this section.

If you provide an email address, you will receive electronic instructions for scheduling your fingerprinting appointment. If you do not provide an email address, you must contact extaccbgc@dfps.texas.gov to get the required information.

Preferred method of contact for scheduling fingerprint appointment:

Email:

Phone number:

SECTION 6 - PRIVACY STATEMENT

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

mailto:extaccbgc@dfps.texas.gov https://www.dfps.state.tx.us/policies/Website/

Revised May 2021

SECTION 7 SIGNATURE

I am the contractor w ho is the subject of this background check, and I agree to th e following (all checkboxes are required):

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: