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Background Statement form

Background Statement form 2026

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The document outlines the instructions and requirements for applicants to disclose their criminal history, pending criminal actions, disciplinary actions related to professional licenses, and substance abuse issues when applying for licensure with the Board of Behavioral Sciences. It specifies what information must be included or excluded, the necessary forms to complete, required attachments such as certified documents and statements of rehabilitation, and the criteria the Board will consider when evaluating an applicant's eligibility for licensure.

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Click ‘Get Form’ to open the Background Statement form in the editor.
Begin with Question A, providing your name as it appears on your application. Answer whether you have any convictions, and if yes, fill in the details of each offense including dates and descriptions.
Proceed to Question B regarding any pending criminal actions. Mark the appropriate option and provide necessary details such as arresting agency and next court date.
In Question C, disclose any past license denials or disciplinary actions. Ensure you include all relevant information about the incident and attach certified documents if required.
Complete Question D by indicating if substance use affects your professional capabilities. Provide details of any rehabilitation programs attended.
Review all entries for accuracy before signing and dating the form at the bottom. If additional space is needed, attach the Additional Narrative Details form.

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Versions	Form popularity	Fillable & printable
2020	4.8 Satisfied (130 Votes)
2017	4 Satisfied (50 Votes)

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How to fill out a background check form?

Completing the Form: The candidate fills out the form with their personal information, including name, address, date of birth, and other relevant details. They must also check the boxes indicating the types of background checks they consent to (e.g., criminal, credit, employment history).

What will stop you from passing a background check?

Common alerts include criminal convictions, a suspended drivers license, a positive drug test, or discrepancies between what the candidate reported and what the background check shows in regards to education or employment history.

What will disqualify you on a background check?

Warning signs on a background check include multiple periods of unexplained unemployment, inconsistent information, short periods of employment, minimal relevant job experience, no required education or training, professional license issues, dangerous criminal convictions, job-related criminal convictions, bad

What would cause a red flag on a background check?

Level 3 Background Check Disqualifying Offenses A Level 3 background check looks at serious felonies and misdemeanors but goes beyond that by checking for offenses such as identity theft, fraud, or other white-collar crimes.

What is a background disclosure form?

The disclosure outlines their intent to obtain a consumer report or background check for employment purposes. They must also secure the candidates signed authorization to run the check. These forms are foundational to the background screening process under the Fair Credit Reporting Act (FCRA).

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