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Form BCC 122215-1 Rev 06/24/2022
STATE OF MAINE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Maine Background Check Center
Notification and Authorization and Release
Driver’s License # and State of Issue/Passport Number:
Date of Birth:
Applicant / Employee Full Legal Name: (First, Middle, Last)
List all Aliases/Maiden/Former Names:
Address:
Phone number:
Position(s) Applied for:
Occupational or Professional Licensing Identification Numbers and Type (if applicable) and State of Issue:
Notice to the Applicant / Employee
This organization has offered you a position contingent upon a clear background check. The organization requires you to
consent to the comprehensive background check. Your eligibility to work in this position is dependent upon whether you
have a disqualifying offense in your background.
You must authorize a release of information relevant to your background, including your criminal history records. This
information will be sent to the Maine Background Check Center and other Federal or State agencies as needed to
investigate your background.
The comprehensive background check requires you to provide personally identifiable information including your name
and date of birth. You may voluntarily provide additional identifying information, including physical description
information in order to speed up your criminal history records check and avoid a false match of criminal records.
The comprehensive background check includes, without limitation, searches State criminal history repositories, public
registries and databases relevant to health or childcare services, and state-maintained databases for abuse and neglect
substantiated findings. Your name will also be checked for a match on the National and Maine sex offender registries. If
you have a professional or occupational license, the licensing authority will be contacted to investigate your licensing
status. Searches may not be limited to the State of Maine, and may include every jurisdiction where you have lived.
If you have a disqualifying offense as defined in 22 M.R.S.A. Ch. 1691 in your background, you will not be eligible to work
in this position, or for any organization subject to Ch. 1691 unless the disqualifying offense meets the criteria for a waiver
pursuant to 22 M.R.S.A. Ch. 1691.
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Form BCC 122215-1 Rev 06/24/2022
Authorization and Release by the Applicant / Employee
Please Initial Each Line
I authorize the employer named herein to request the Maine Background Check Center to conduct the
comprehensive background check described above.
I authorize any duly assigned representative of the Maine Background Check Center to conduct a background
investigation and receive any criminal history record information pertaining to me, which may be in the files of any
State or local criminal justice agency.
I release the Maine Background Check Center from any liability for the release of information concerning my
background to employers.
Acknowledgements of the Applicant / Employee
Please Initial Each Line
I understand my personal identification information will be disclosed to Federal, State or local agencies in
conjunction with the application process, and I consent to such disclosure.
I understand that the Maine Background Check Center may use the criminal justice information systems to obtain
current criminal history records, and that my criminal records will be monitored for new events.
I understand that records of civil and criminal disqualifying offenses as defined in 22 M.R.S.A. Ch. 1691 may result
in a permanent or temporary employment ban for this position.
I further understand that prior to the receipt of a finalized non-disqualifying background check report; this employer
can only employ me conditionally for up to sixty (60) days.
I acknowledge that I have been provided with the notices and appeal information described in 22 M.R.S.A. Ch. 1691
as well as the notice of an opportunity to correct inaccuracies in my record information.
I agree to defend, indemnify and hold harmless the Federal and State agencies and agency employees to whom this
background check request is presented from and against all claims, damages, lawsuits, losses and expenses,
including reasonable attorney's fees arising out of or by reason of complying with this request.
**Any individual who fails to make a full and complete disclosure on an application or a full and complete disclosure of any
information required to obtain a criminal history record is subject to civil and criminal penalties.
_______________________________________ ___________________
Signature of Applicant or Employee Date
_______________________________________ ___________________
Signature of Legal Guardian* Date
*A legal guardian must sign this form if the applicant or employee is a minor.
**WARNING: Title 18, Section 1001 of the U.S. Code, states whoever, in any matter within the jurisdiction of the executive,
legislative, or judicial branch of the Government of the United States, knowingly and willfully –- (1) falsifies, conceals, or covers
up by any trick, scheme, or device a material fact; (2) makes any materially false, fictitious, or fraudulent statement or
representation; or (3) makes or uses any false writing or document knowing the same to contain any materially false, fictitious,
or fraudulent statement or entry; shall be fined under this title, imprisoned not more than 5 years or, if the offense involves
international or domestic terrorism (as defined in section 2331), imprisoned not more than 8 years, or both.
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Form BCC 122215-2 Rev 06/24/2022
STATE OF MAINE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Maine Background Check Center
Voluntary Consent for Disclosure of Personal Description
Attention Applicants / Employees
This organization is required to conduct a comprehensive background check, including a name-based criminal history
records check, as a condition for employing you in this position. Your organization must enter your name and date of
birth to conduct a name-based criminal record check. It is common for more than one person to have the same or similar
names and dates of birth or similar personal descriptions. Helping your organization enter accurate and detailed
information about you and your physical description helps decrease the chance that a false criminal record match occurs.
You may voluntarily allow this employer to enter other personal descriptors such as height, weight, eye color, hair color,
gender, race, and place of birth. Your organization will enter this information into the Maine Background Check Center
(MBCC) for comparison to State Bureau of Identification (SBI) criminal records.
If the SBI system does not find a matching record for the information submitted a "NO OFFENSE FOUND” report will be
sent to the MBCC. The MBCC will inform your organization that you do not have a criminal record in the State of Maine.
If the SBI system finds a matching record for your name and date of birth, the MBCC will receive criminal history record
information from SBI that includes personal descriptors to help make a positive identification. Without your personal
descriptors, a name and date of birth check could result in a “false positive,” meaning that your name matches one or
more possible criminal records, but the record is not yours. Therefore, the MBCC cannot eliminate you as the person
listed in the name-matched records. Your organization, the MBCC, and the SBI would require more time and further
information in order to determine whether you have or do not have a criminal record that will disqualify you from
working in this position.
Mandatory Information
First Name:
Middle Name:
Last Name:
Address:
City, State, Zip:
Maiden or Previous Married Name(s):
Previous Name(s) / Aliases / Other:
Date of Birth:
Voluntary Information
Eye Color:
□ Black ☐ Blue ☐ Brown ☐ Green ☐ Gray ☐ Hazel
□ Maroon ☐ Pink ☐ Unknown ☐ Multi-colored
Hair Color:
□ Bald ☐ Black ☐ Blonde or Strawberry ☐ Blue ☐ Brown ☐Green
□ Gray or Partially Gray ☐ Orange ☐ Purple ☐ Pink ☐ Red or Auburn
□ Sandy ☐ White ☐ Unknown
Race:
□ American Indian / Alaskan Native ☐ Asian or Pacific Islander ☐ Black ☐ Unknown ☐ White
Gender:
□ Female ☐ Male ☐ Other
Height: Feet Inches
Weight: Pounds
Place of Birth (State and Country):
Signature of Applicant Date
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Form BCC 01142016-7 Rev 06/24/2022
STATE OF MAINE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Maine Background Check Center
Background Check Report
Correcting Inaccurate Information
Applicants or Employees
You have the right to challenge and correct inaccurate information found during a comprehensive background
check. If you know that information presented on the Maine Background Check Center (MBCC) report is
incorrect or incomplete you must seek a challenge and ask for a correction to the reporting entity as follows:
State Criminal Records: You must challenge incorrect or incomplete state criminal record information
maintained by state criminal record repositories directly to the state where the record is maintained.
State of Maine criminal history records may be challenged by contacting the Maine State Bureau of
Identification (SBI) directly by writing the State Bureau of Identification, State House Station #42, Augusta, ME
04333-0042, or online at http://www.maine.gov/dps/Sbi/contact.html. The SBI is responsible for correcting
the record and notifying the MBCC. The MBCC will issue a final background check report to your employer
upon completion of the error correction process based on the final record released by the SBI.
Federal Criminal Records: You must challenge incorrect or incomplete criminal record information maintained
by the Federal Bureau of Investigation (FBI) by communicating directly with the Federal or State agency
responsible for submitting the criminal record to the FBI. Alternatively, you may challenge the accuracy of the
FBI record directly to the FBI by writing the Criminal Justice Information Services (CJIS) Division, ATTN:
Summary
Request, 1000 Custer Hollow Road, Clarksburg, WV 26306, or online
at
https://www.fbi.gov/services/cjis/identity-history-summary-checks. The FBI is responsible for correcting the
record
and notifying the Maine Background Check Center, and a revised Background Check Report can be
issued. (See
28 CFR §§16.30 - 16.34)
Public Registries: If you believe that disqualifying offense information listed on a Federal or State registry is
incorrect or incomplete, you must contact the agency responsible for maintaining the registry.
□ Office of Inspector General (OIG) List of Excluded Individuals/Entities (LEIE)
E-mail Address: [email protected]
Telephone: (202) 691-2311
Mailing Address: HHS, OIG, OI, Attn: Exclusions, P.O. Box 23871, Washington, DC 20026
Website: https://exclusions.oig.hhs.gov/
□ The Dru Sjodin National Sex Offender Public Website (NSOPW)
To correct any errors in registration information, you must contact the state registration officials
where the record is held.
Website: http://www.nsopw.gov/
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Form BCC 01142016-7 Rev 06/24/2022
State Registries: To correct errors on registry information, you must contact the officials that maintain the
registry in each state. The Background Check Center checks the following registries:
□ Maine Sex Offender Registry
Contact the Sex Offender Registry (State Bureau of Identification)
E-mail Address: [email protected]
Telephone: (207) 624-7270
□ Maine Registry of Certified Nursing Assistants (CNA) and Direct Care Workers (DCW)
Contact the CNA and DCW registry
E-mail Address: [email protected]
Telephone: (207) 624-7300
□ Maine Program Integrity Excluded Providers: List of Excluded Individuals/Entities
Contact Maine Department of Health and Human Services, Program Integrity Unit
Website: https://mainecare.maine.gov/mhpviewer.aspx?FID=MEEX
Telephone: (207) 287-4660 TTY: Maine Relay 711
Mailing Address: 221 State Street, Augusta, ME 04330
□ Maine Background Check Center: Request for correction of errors
If an error appears on a Maine Background Check Center Report you must follow the
procedures outlined in the Maine Background Check Program Rules by contacting MBCC
E-mail
:
Telephone: 888-572-5839 TTY: Maine Relay 711
Mailing Address: 11 State House Station, Augusta, ME 04333
□ Out of State Registries
The employer has the option to search Out of State Registries based on information you
provide in your application. If there is an error found in information listed on registries in other
states, you must contact that particular registry for corrections.
□ Professional Licensing
If you believe that information provided about your professional license is incorrect or
incomplete, you must contact the agency responsible for the licensing data.
