Revised 10/18/19
SUU LiveScan Fingerprint Authorization Form
For Authorized Adults Working with Minors
As defined by Policy 5.64 Minors on Campus and at University-Sponsored Events, you have been identified as an Authorized Adult
working with minors in a Southern Utah University sponsored or co-sponsored program or activity. As such, you are required to
complete a LiveScan Fingerprint background check.
To ensure the completion of your background check, please carefully read and follow the steps below.
Step 1: Complete and sign the following applicant information:
Agency Code: B1075
RFP/Statute: UCA 53G-11-402
Type of Background Check: NFUF
First Name: ______________________________ Middle Name: ______________________________
Last Name: ______________________________ Alias/Aliases: _______________________________
Date of Birth _____________ Last 4 digits of Applicant’s Social Security Number ____________________
I, the undersigned applicant, certify that the above information is true and correct and that I have completed the Utah Consent to
Background Check form.
Applicant Signature: _______________________________________ Date: __________________
Step 2: Get approval from the Activity’s Program Director.
You will need approval from the Program Director of the University-sponsored or co-sponsored program or activity involving minors.
The Program Director’s signature and billing index are required.
Program Director Name: ___________________________________
Program Name: _________________________________________
Department Name: ______________________________
Department Accounting Index: ______________________________
I, the undersigned Program Director, approve the background check for the above applicant and authorize the use of the above
accounting index to cover the cost of the background check and the SUU Police Department fee.
Program Director Signature: __________________________________
Step 3: Complete your fingerprint background check with the SUU Police Department
The SUU Police Department is available to take fingerprints on Tuesdays and Wednesdays between 2:00 PM and 5:00 PM located at
36 North 300 West Cedar City, Utah. Please call to check availability at 435-586-7793. You must present this form (with completed
steps 1 &2) and a current, valid government-issued photo identification (i.e. driver’s license, State ID, Military ID, etc.) in order to be
fingerprinted.
Authorizing Signature (Fingerprint Technician)____________________________ Date: ________________
Step 4 : Return this completed form to the SUU Human Resources Office.
The Human Resources office is located in room 106 of the Bennion Bldg. 477 W. University Blvd. Cedar City, Utah.
Representatives from the Human Resources Office shall “Approve” or “Not Approve” applicants to work in programs involving
minors based on background check results received from Utah BCI.
HR Representative Name: _____________________________________
Date: ___________________________
Approved – Above applicant is approved to work in programs working with minors.
Not Approved – Above applicant is not-approved to work in programs with minors.
