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NEVADA STATE CONTRACTORS BOARD APPLICANT BACKGROUND DISCLOSURE STATEMENT (Nevada State Contractors Board)

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Nevada State Contractors Board
Background Disclosure Statement and Fingerprint Waiver (Revised 04/2021)
Page 1 of 2
NEVADA STATE CONTRACTORS BOARD APPLICANT BACKGROUND DISCLOSURE
STATEMENT AND AUTHORIZATION FOR RELEASE OF INFORMATION
A separate form MUST be completed by EACH Person including the Qualified Individual
BUSINESS NAME: ______________________________________________________
NRS 624.263 and NRS 624.265 authorizes the Nevada State Contractors Board (NSCB) to conduct background
investigations, obtain credit reports, and to request fingerprints for submission to the Nevada Highway Patrol (NHP) and the
FBI for a determination of identity, fugitive status or prior criminal history.
FIRST NAME
MIDDLE NAME
LAST NAME
SUFFIX
OTHER NAME USED
DATE OF BIRTH
CITY & STATE OF BIRTH
EMAIL ADDRESS (CANNOT BE A THIRD PARTY)
RESIDENCE ADDRESS (AND MAILING ADDRESS IF DIFFERENT)
CITY
ZIP
SOCIAL SECURITY NUMBER
-
-
OR INDIVIDUAL TAX ID NUMBER
9
-
-
A COPY OF THE FOLLOWING MUST BE PROVIDED WITH THIS FORM:
• A valid Driver’s License or Government Issued Photo I.D.
FINGERPRINT AND CRIMINAL BACKGROUND CHECKS
The Board will conduct a background check using information from the Federal Bureau of Investigations (FBI) and the Nevada Criminal History
Repository. These records are likely to include all instances of criminal activity, including those matters that may have been sealed, expunged, had the
charges reduced or dismissed. If a criminal history is found, an investigation will be conducted and you will be requested to provide supporting
documentation.
1. Have you ever been convicted of, or pled guilty or no contest to any crime, or, are any criminal charges pending against you?
No Yes
Applications are not automatically denied because of information obtained through the background disclosure and criminal history verification. When
reviewing prior criminal convictions, the NSCB considers such additional factors as the seriousness of the crime, the time that has passed since the
conviction and any evidence of rehabilitation the applicant submits. It is your responsibility to provide any supporting documentation requested by the
Board related to any past convictions or pending criminal charges.
FINANCIAL DISCLOSURES
2. Within the last 3 years, have you filed or been adjudicated Bankrupt under your individual name, a corporate name or any other business entity
name?
No Yes – Attach a complete copy of the proceedings, including a schedule of creditors listed in the bankruptcy petition. If the
bankruptcy has not been discharged, include your plan of reorganization and proof of compliance.
3. Do you anticipate filing bankruptcy within the next 6 months?
No Yes
4. Have you, or any business entities of which you were a member, partner, officer, director, or associate received any notice of liens, suits,
judgments, or claims (including tax claims) which remain unresolved or unsatisfied – OR – Are there now any unpaid past due bills for
materials, services rendered, or labor?
No Yes – Attach a detailed explanation.
5. Have you, or any business entities of which you were a member, partner, officer, director, associate, or qualified employee had a contractor’s
license denied, suspended, revoked, or otherwise disciplined BY NEVADA OR ANY OTHER STATE? Are there any disciplinary proceedings
currently pending against you, or any license on which you have appeared IN NEVADA OR ANY OTHER STATE?
No Yes – Attach a detailed explanation including the name of the state in which the license was held, license number, and
business name.
6. Do you have a proprietary interest (i.e., ownership, stock, shares) in this applicant? (This question does not pertain to sole proprietors).
No Yes – Percentage Owned: ________%
For Board Staff Only
Live Scan Prints
Hard Copy Prints
Nevada State Contractors Board
Background Disclosure Statement and Fingerprint Waiver (Revised 04/2021)
Page 2 of 2
In order to comply with the requirements of Nevada’s Department of Public Safety, fingerprint cards and LiveScan fingerprints cannot be
accepted until after you submit your application and completed Fingerprint Background Waiver form(s) to the Board.
Once these forms has been submitted to the Nevada State Contractors Board you may proceed with obtaining the required fingerprints.
In consideration for processing my application for a Nevada State Contractor’s License, I, the undersigned whose name and personal
information voluntarily appear above, do hereby and irrevocably agree to the following:
1. I hereby authorize the NEVADA STATE CONTRACTORS BOARD (hereinafter “BOARD”) to submit a set of my fingerprints to the
Nevada Department of Public Safety, Records Bureau for the purpose of accessing and reviewing Nevada and National criminal history
records that may pertain to me. In giving this authorization, I expressly understand that the information may include information pertaining
to notations of arrest, detainments, indictments, information or other charges for which the final court disposition is pending or is unknown
to the above referenced agencies. For records containing final court disposition information, I understand that the release may include
information pertaining to dismissals, acquittals, convictions, sentences, correctional supervision information and information concerning the
status of my parole or probation when applicable. Further, I understand that the information may include similar information obtained from
other local, state and federal criminal justice agencies and may include information pertaining to convicted person data, outstanding arrest
warrants, missing persons and current and/or prior gaming and non-gaming sheriff’s work cards that were issued to me.
2. I understand that I may review and challenge the accuracy of any and all criminal history records which are returned to the BOARD.
3. I hereby release from liability and promise to hold harmless under any and all causes of legal action, the State of Nevada, the Nevada
State Contractors Board, its officer(s), agent(s) and/or employee(s) who conducted my criminal history records search and provided
information to the BOARD 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
and the BOARD on the basis of their disclosures. I have signed this release voluntarily and of my own free will.
4. In giving the above authorization, I understand that all information provided to the BOARD may be reviewed by the BOARD or any other
employee within the BOARD’S organization deemed necessary to make an informed decision. This information is confidential, as relating
to a third party beyond that of the BOARD and of the criminal justice agencies in the performance of their official duties, and may not be
further disseminated.
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.
PURSUANT TO NRS 199.120, I CERTIFY THAT I HAVE CAREFULLY REVIEWED THE INFORMATION CONTAINED IN THIS
DOCUMENT AND I ATTEST TO THE TRUTH AND ACCURACY OF THE INFORMATION CONTAINED IN THIS BACKGROUND
DISCLOSURE STATEMENT UNDER PENALTY OF PERJURY.
Signature: ____________________________________________ Date: _______________________
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
__________________ ___________________
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:
P
LEASE PRINT
Last Name First Name Middle
Applicant’s Signature:
Date:
Agency Account #:
Agency Representative:
PLEASE PRINT
Last Name First Name Middle
Agency Representative Signature:
Date:
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Completed 26 April 2021

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