Residential Facility Employment

Medium

Three forms are required for fingerprint-based criminal background checks for employment in a Supervised Independent Living Program and in a residential facility including a Qualified Residential Treatment Program (QRTP) or a Psychiatric Residential Treatment Facility (PRTF)

Please note: Not all forms are compatible with Mac programs.

Instructions:
How to Complete Forms and Submit a Fingerprint-based Criminal Background Check


Form 1
Personal Authorization for Criminal History Record Information Inquiry (SFN 829)
(This form must be typed.)

Additional Address History
Use as needed and attach along with SFN 829

Form 2a
Criminal History Record Check Request Form (SFN 60688)
(This form must be typed; Signature must be handwritten.)

Form 2b (PRTF ONLY)
Non-Criminal Justice Request Form (SFN 50744)
This form must be typed. No signature is required. IMPORTANT NOTE: Dakota Boy's & Girls Ranch Employees must complete Form 2a AND Form 2b.

Form 3
Fingerprint Identity Verification (SFN 836)
(Print blank form. This form is not required for PRTF-only employees.)

If you have lived outside of North Dakota during the past five years, click on each state you have lived in (below) to see if you need to:

  • Complete additional out-of-state authorization forms for each state you have lived in,
  • Provide a copy of a valid photo ID or a copy of your social security card, and/or
  • Provide an extra set of fingerprint cards (must obtained from a law enforcement agency or an authorized third-party fingerprinting agency)

If any of the above are required, they must be mailed to the Bismarck office. Please DO NOT send anything directly to other states.

Individual State Background Check Forms

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Individual State Background Check Forms

Select from the list below. PLEASE READ ALL INSTRUCTIONS CAREFULLY!

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Alabama / Alaska / Arizona / Arkansas

Alabama

The signature on the form below must be witnessed.

Child Protective Services form

Criminal History Record Information form (PRTF only)


Alaska

Child Protective Services form 

Criminal History Record Information form (PRTF only)


Arizona

Child Protective Services form 


Arkansas

  • Complete the form below - notary not necessary.
  • Due to their requirements, a second form will be generated by the CBCU and it will be emailed directly to you.
  • The online-generated form DOES require a notary.
  • Mail the completed form to the CBCU.
  • Please Do NOT mail it to Arkansas.

Child Protective Services form 

Criminal History Record Information (PRTF only)

California / Colorado / Connecticut

California

No forms are required.


Colorado

The form below must be typed. Photo ID required.

Child Protective Services form


Connecticut

Child Protective Services form

Criminal History Record Information form (PRTF only)

Delaware / Florida / Georgia / Hawaii

Delaware

Complete Part 1 before printing the form for signature and date.

Child Protective Services form 

Criminal History Record Information form (PRTF only)


Florida

Child Protective Services form (36kb pdf)


Georgia

Child Protection Services form (651kb pdf)


Hawaii

Child Protective Services form (24kb pdf)

Idaho / Illinois / Indiana / Iowa

Idaho

Child Protective Services form

Criminal History Record Information form (PRTF only)


Illinois

Child Protective Services form (415kb pdf)


Indiana

  • Online form required.
  • You will receive email instructions upon the department initiating a registry search.

Iowa

No forms are required.

Kansas / Kentucky / Louisiana

Kansas

Child Protective Services form 


Kentucky

Copy of valid photo ID is required.

Criminal History Record Information form (PRTF only)


Louisiana

The form below requires a photo ID.

Child Protective Services form 

Criminal History Record Information form (PRTF only)

Maine / Maryland / Massachusetts / Michigan

Maine

  • Complete only if you are 18 yrs old or older
  • This form CANNOT BE TYPED

Child Protective Services form 


Maryland

The form below must be typed. The signature must be notarized.

Child Protective Services form 


Massachusetts

Criminal History Record Information form (PRTF only)


Michigan

A copy of a valid photo ID is required.

Child Protective Services form 

Minnesota / Mississippi / Missouri / Montana

Minnesota

Child Protective Services form 

Criminal History Record Information form (PRTF only)


Mississippi

  • Online form required.
  • You will receive email instructions upon the department initiating a registry search.

Criminal History Record Information form (PRTF only)


Missouri

You will receive email instructions after the department receives your CPS background check request. 

Criminal History Record Information form (PRTF only)

 


Montana

The signature on the form below must be notarized.

Child Protective Services form (74kb pdf)

Nebraska / Nevada / New Hampshire / New Jersey

Nebraska

  • The signature on the form below must be notarized.
  • If the applicant is not 20 years old or older, the applicant's parent or guardian must sign the form.

Child Protective Services form 

Criminal History Record Information form (PRTF only)


Nevada

The form below requires a photo ID, DO NOT NOTARIZE.

Child Protective Services form 


New Hampshire

The signature on the form below must be notarized.

Child Protective Services form 

Criminal History Record Information form (PRFT only)

New Jersey

Child Protective Services form (90kb pdf)

New Mexico / New York / North Carolina

New Mexico

  • The form below must be typed.
  • The signature must be notarized.

Child Protective Services form (1mb pdf)


New York

The signature on the form below must be notarized.

Child Protective Services form (84kb pdf)


North Carolina

The form below must be typed and requires a copy of a valid photo ID.

Child Protective Services form (1.3mb pdf)

Ohio / Oklahoma / Oregon

Ohio

  • Form below must be typed.
  • Requires a copy of a valid photo ID and a copy of the applicant's social security card.
  • Results will be mailed to the applicant.
  • Applicant must forward them to the Criminal Background Check Unit in Bismarck.

Child Protective Services form 

Criminal History Record Information form (PRTF only)


Oklahoma

Does not maintain a public registry.


Oregon

The form below must be typed.

Child Protective Services form (837kb Word doc)

Pennsylvania / Rhode Island / South Carolina / South Dakota

Pennsylvania

Child Protective Services form


Rhode Island

Criminal History Record Information form (PRTF only)


South Carolina

You will receive email instructions after the department receives your background check request.


South Dakota

The signature on the form below must be notarized.

Child Protective Services form 

Criminal History Record Information form (PRTF only)

Tennessee / Texas / Utah / Vermont / Virginia

Tennessee

No forms are required.


Texas

The signature on the form below must be notarized.

Child Protective Services form 


Utah

The form below requires a photo ID.

Child Protective Services form 

Criminal History Record Information form (PRTF only)

An extra set of fingerprint cards are required. 

Criminal History Record Information form 


Vermont

No forms are required.


Virginia

  • The signature on the form below must be notarized.
  • The form must be printed 2-SIDED (on one sheet of paper).

Child Protective Services form (198kb pdf)

Washington / Washington, D.C. / West Virginia / Wisconsin / Wyoming

Washington

The form below must be typed.

Child Protective Services form (166kb pdf)


Washington, D.C.

  • The signature on the form below must be notarized.
  • The form requires full 18 years of address history.

Child Protective Services form

Criminal History Record Information form (PRTF only) 


West Virginia

Child Protective Services form


Wisconsin

This form requires a witness signature.

Child Protective Services form


Wyoming

Instructions will be emailed to the applicant.

Medium

Contact Information

Criminal Background Check Unit
600 E. Boulevard Avenue, Department 325
Bismarck, ND 58505-0250
Phone: (701) 328-7575
Toll-Free: (800) 472-2622, 711 (TTY)
Fax: (701) 328-0358
Email: dhscfscbc@nd.gov