Fillable Fingerprint Background Waiver (Department of Motor Vehicles )

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Fingerprint Background Waiver (Department of Motor Vehicles )

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0505RCCD-003(08/2020rev)
Fingerprint Background Waiver Page 1 of 2
Fingerprint Background Waiver
As an applicant who is the subject of a national fingerprint-based criminal history record check for a
noncriminal justice purpose (such as an application for employment or a license, an immigration or
naturalization matter, security clearance, or adoption), you have certain rights which are discussed below.
All notices must be provided to you in writing. These obligations are pursuant to the Privacy Act of 1974,
Title 5, United States Code (U.S.C.) Section 552a, and Title 28 Code of Federal Regulations (CFR), 50.12,
among other authorities.
1. You must be notified by _________________________________________ (name of requesting agency) that your
fingerprints will be used to check the criminal history records of the FBI and the State of Nevada.
2. Authority: The FBI’s acquisition, preservation, and exchange of fingerprints and associated information
is generally authorized under 28 U.S.C. 534. Depending on the nature of your application, supplemental
authorities include Federal statutes, State statutes pursuant to Pub. L. 92-544, Presidential Executive
Orders, and federal regulations. Providing your fingerprints and associated information is voluntary;
however, failure to do so may affect completion or approval of your application.
3. Principal Purpose: Certain determinations, such as employment, licensing, and security clearances,
may be predicated on fingerprint-based background checks. Your fingerprints and associated
information/biometrics may be provided to the employing, investigating, or otherwise responsible
agency, and/or the FBI for the purpose of comparing your fingerprints to other fingerprints in the FBI’s
Next Generation Identification (NGI) system or its successor systems (including civil, criminal, and
latent fingerprint repositories) or other available records of the employing, investigating, or otherwise
responsible agency. The FBI and/or the Central Repository for Nevada Records of Criminal History
may retain your fingerprints and associated information/biometrics in NGI after the completion of this
application and, while retained, your fingerprints may continue to be compared against other
fingerprints submitted to or retained by NGI.
4. Routine Uses: During the processing of this application and for as long thereafter as your fingerprints
and associated information/biometrics are retained in NGI
and/or Central Repository for Nevada
Records of Criminal History, your information may be disclosed pursuant to your consent, and may be
disclosed without your consent as permitted by the Privacy Act of 1974 and all applicable Routine Uses
as may be published at any time in the Federal Register, including the Routine Uses for the NGI system
and the FBI’s Blanket Routine Uses. Routine uses include, but are not limited to, disclosures to:
employing, governmental or authorized non-governmental agencies responsible for employment,
contracting, licensing, security clearances, and other suitability determinations; local, state, tribal, or
federal law enforcement agencies; criminal justice agencies; and agencies responsible for national
security or public safety.
5. If you have a criminal history record, you should be afforded a reasonable amount to time to correct or
complete the record (or decline to do so) before the officials deny you the employment, license, or
other benefit based on information in the FBI criminal history record. The procedures for obtaining a
change, correction, or update of your FBI criminal history record as set forth at, 28 CFR 16.34 provides
for the proper procedure to do so.
Applicant:
__________________ ___________________
Initial Date
DMV
0505RCCD-003(08/2020rev)
Fingerprint Background Waiver Page 2 of 2
6. If agency policy permits, the officials may provide you with a copy of your FBI criminal history record
for review and possible challenge. If agency policy does not permit it to provide you a copy of the
record, you may obtain a copy of the record by submitting fingerprints and a fee to the FBI. Information
regarding this process may be obtained at
https://www.fbi.gov/services/cjis/identity-history-
summary-checks and https://www.edo.cjis.gov .
7. If you decide to challenge the accuracy or completeness of your FBI criminal history record, you should
send your challenge to the agency that contributed the questioned information to the FBI.
Alternatively, you may send your challenge directly to the FBI by submitting a request via
https://www.edo.cjis.gov
. The FBI will then forward your challenge to the agency that contributed the
questioned information and request the agency to verify or correct the challenged entry. Upon receipt
of an official communication from that agency, the FBI will make any necessary changes/corrections to
your record in accordance with the information supplied by that agency. (See 28 CFR 16.30 through
16.34.)
8. You have the right to expect that officials receiving the results of the fingerprint-based criminal history
record check will use it only for authorized purposes and will not retain or disseminate it in violation of
federal or state statute, regulation or executive order, or rule, procedure or standard established by the
National Crime Prevention and Privacy Compact Council.
9. I hereby authorize ______________________________________________ (name of requesting agency), to submit a set
of my fingerprints to the Nevada Department Public Safety, Records Bureau for the purpose of
accessing and reviewing State of Nevada and FBI criminal history records that may pertain to me.
10. I hereby release from liability and promise to hold harmless under any and all causes of legal action,
the State of Nevada, its officer(s), agent(s) and/or employee(s) who conducted my criminal history
records search and provided information to the submitting agency for any statement(s), omission(s),
or infringement(s) upon my current legal rights. I further release and promise to hold harmless and
covenant not to sue any persons, firms, institutions or agencies providing such information to the State
of Nevada on the basis of their disclosures. I have signed this release voluntarily and of my own free
will.
A reproduction of this authorization for release of information by photocopy, facsimile or similar process,
shall for all purposes be as valid as the original.
In consideration for processing my application I, the undersigned, whose name and signature voluntarily
appears below; do hereby and irrevocably agree to the above.
Applicant’s Name:
PLEASE PRINT
Last Name
First Name
Middle
Applicant’s Signature:
Date:
Agency Account #:
Agency Representative:
PLEASE PRINT
Last Name
First Name
Middle
DMV
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Fingerprint Background Waiver (Department of Motor Vehicles )

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Completed 24 December 2020

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