LIVESCAN PRE-REGISTRATION APPLICATION

Name

Date of Birth

Social Security Number

Height

Gender

Male

Female

Weight

Eye Color

Hair Color

Race/Ethnicity *

Black

White

Asian/Pacific Islander Native American

Other

Citizenship

State

City

Zip Code

Phone Number:

Driver’s License Number:

Please select one of the following: *

REASON FOR REQUEST

Gold Seal/Adoption (Enter Authorization Number if applicable)

Gold Seal/Letter/VISA

Immigration/VISA

Individual Challenge

Individual Review

Attorney/Client (Written Authorization Required)

Mailing Information:

Name

Street Address

City

State

Zip Code

AGENCY

Agency Authorization Number:

ORI Number

Background Disclosure Statement

PLEASE READ: Completion of this form is required under the provisions of the Maryland Code: Family Law: Title 5. Children: Subtitle 5. Child Care; Foster Care: Part VI. Criminal Background Investigations for Employees of Facilities and Other Individuals that Care for, or Supervise Children: § 5- 563. Failure to comply will result in denial of employment with Prince George’s County Public Schoals. For additional information or questions, contact the Human Resources Background Unit at 301-952-7831 or via CpS.OF; email, hr.backgroundunit:

Social Security Number (LAST 4 DIGITS ONLY)

Driver's License # and Issuing State

Country of Citizenship

Print Full Name

Other Names Used (including Maiden Name)

Race

Single choice

Male

Female

Hair Color

Eye Color

Height

Weight

Date of Birth

State or Country you were born in

Home Phone

Cell Phone

Current Street Address

City

State

Zip Code

Country

Address for the Past Seven Years

City

State

Zip Code

City

Start Date

End Date

State

Zip Code

Start Date

End Date

Have you ever been arrested or convicted, received PBJ, have pending charges without final disposition, been found not criminally responsible, or had a case placed on a STET docket, for any offense other than a minor traffic violation?

Yes

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*If YES, provide a written explanation when submitting this form. You may be required to supply additional information, including relevant legal court documents. Please use the space below to write a brief statement.

Have you ever received a final finding of “Indicated” in a child abuse or neglect investigation by any Department of Social Services? (“Final” means all appeal rights are exhausted.) If yes, state the state/county and date (DD/MM/YYYY). *

Yes

I certify that the above statements are true, complete, and accurate and I understand that the misrepresentation or omission of facts called for in the resume, interview, or other employment material collected during the hiring process may prohibit consideration for volunteer or contracting services with Prince George's County Public Schools and is cause for immediate dismissal, if employed.

I also certify that if employed with Prince George's County Public Schools, it is my responsibility to report to the Division of Human Resources, any criminal convictions, probation before judgment (PBJ) dispositions, or pending charges that may occur after my start date.

Failure to report arrests, criminal convictions, PBJ disposition, or any pending criminal charges may result in termination of my employment with Prince George County Public Schools.

CONSENT FOR RELEASE OF INFORMATION

PLEASE COMPLETE THIS FORM ONLINE AND THEN PRINT

Part I: PURPOSE OF SEARCH (if you are completing this form on your own behalf, all fields in Part | must be campleted by you)

A. RELEASE TO SELF:

1. To determine if I have been found responsible for an "indicated" disposition for a child abuse or neglect investigation.

2. To determine if I have any remaining appeal rights.

Agency/Individual Name

Name of Agency Representative/Individual

Agency/individual Address (Te include street # and name, unit type and #, city, state, and zip cade}

Rep/Ind Phone Number

Representative/Individual Email

Part Il: SEARCH INFORMATION (To be completed IN FULL by individual whose name is being searched)

APPLICANT’S LAST NAME

FIRST NAME

MIDDLE NAME (Full)

MAIDEN/BIRTH NAME

SOCIAL SECURITY NUMBER

A - Number

DATE OF BIRTH

GENDER

RACE

OTHER NAMES USED

NUMBER

STREET NAME

UNIT

CITY

STATE

ZIP CODE

COUNTRY

DAYTIME TELEPHONE NUMBER

EMAIL ADDRESS

CURRENT SPOUSE

LAST NAME

FIRST NAME

MIDDLE NAME (Full)

DATE OF BIRTH

FULL NAMES OF ALL CHILDREN (To include adult children and children not residing with you). If more than 2 children, attach additional paper if necessary.

FIRST NAME

LAST NAME

MIDDLE NAME (Full)

DATE OF BIRTH

FIRST NAME

LAST NAME

MIDDLE NAME (Full)

DATE OF BIRTH

Do you currently reside, or have you previously resided, in Maryland?

Yes

Do you currently volunteer, or have you previously volunteered, in Maryland?

Yes

PRIOR ADDRESSES (List all within the past 7 years in Maryland):

Number

Street Name

City

State

Zip Code

Date

Part III: AUTHORIZATION Pursuant to Code of Maryland Regulation 07.02.07.21, pertaining to the confidentiality of reports and records concerning child abuse or neglect; I hereby authorize the Maryland Department of Human Services to notify Prince George's County Public Schools (agency or individual as listed in Part I) as to whether a local department of social services has identified me as responsible for "indicated" child abuse or neglect for the purpose of determining my suitability for employment or volunteer service with children.

REVIEW THAT ALL SECTIONS ABOVE ARE COMPLETE BEFORE MOVING TO PART IV.

PART IV: MANDATORY ACKNOWLEDGEMENT AND SUBMISSION REQUIREMENTS

The section labeled PART IV: APPLICANT SIGNATURE AND ACKNOWLEDGEMENT on Page 5 of this document is a mandatory component of the submission process. It must be fully completed, dated, and signed by the applicant and appropriate party prior to the form being submitted for review and processing.

Please be advised that any forms received without the required completion of Part IV, the Applicant Signature and Acknowledgement section, on Page 5 will be deemed incomplete. Such submissions cannot be processed and WILL BE RETURNED to the sender, which will cause significant delays in the review and approval timeline. Ensure the appropriate fields in Part IV are accurately completed and the required signature is present to avoid further delay.

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