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c ct t t st t v t s. If c t , a copy may be submitted from the cy ct y t t ss B t st v s ty t t f P c Safety. You must go, in person, to the original agency, complete a “Background Check Release” form, and bring the copy to the Department of Public Safety at Missouri Baptist University, main campus. t f f ck c ck cc t . P v st f st ct s t c t t s t f y st t c t :

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Pursuant to the National Child Protection Act of 1993 (NCPA), as amended by the Volunteers for Children Act (VCA), this form must be completed and signed by every current or prospective applicant, employee, volunteer, and contractor/vendor, for whom criminal history records are requested by a qualified entity under these laws.

I hereby authorize, MISSOURI BAPTIST UNIVERSITY

to submit a set of my fingerprints to the Missouri State Highway Patrol (MSHP) for the purpose of accessing and reviewing Missouri open and closed criminal history records and national criminal history records that may pertain to me. I understand that I would be able to receive any Missouri records pursuant to 43.540 RSMo from the MSHP, and any national criminal history record directly from the FBI, pursuant to 28 CFR Sections 16.30–16.34, and that I could then freely disclose any such information to whomever I chose. By signing this Waiver Agreement, it is my intent to authorize the dissemination of any Missouri and national criminal history record that may pertain to me to the qualified entity.

I understand that, until the criminal history background check is completed, the qualified entity may choose to deny me unsupervised access to children, the elderly, or individuals with disabilities. I further understand that, upon request, the qualified entity will provide me a copy of the criminal history background report, if any, received on me and that I am entitled to challenge the accuracy and completeness of any information contained in any such report. I may obtain a prompt determination as to the validity of my challenge before a final decision is made.

Yes, I have (OR) No, I have not been convicted of or plead guilty to a crime.

If yes, describe the crime(s) and the particulars in the space below:

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iss ri tate i way atr l rimi al sti e rmati ervi es ivisi

V WA V A N AN A N Missouri Volunteer and Employee Criminal History Service (MoVECHS)

Section One: Agency Information

5 7 2 6

MOVECHS0Z

Section Two: The Missouri Automated Criminal History Site (MACHS)

Section Three: Registration Confirmation (for applicant or agency use)

Missouri State Highway Patrol Applicant Fingerprint Services of Missouri Applica t Fi ge p i t Fo m o tate a d FB C imi al Hi to y Backg o d C eck

MBUWestCountyMainCampus

MissouriBaptistUniversityDepartmentofPublicSafety OneCollegeParkDr.St.Louis,MO63141HoursofOperation Monday–Friday7:00am–7:00pmSaturday–ByappointmentonlySunday–Closed TelephoneNumber(314)744-5355

St.LouisFingerprints,LLC2716TelegraphRd,STE109St.Louis,MO63125 HoursofOperation Monday–Friday9:00am–4:00pmSaturday–9:00am–1:00pmCLOSEDFORLUNCHFROM1:00PM–2:00PM TelephoneNumber(314)359-3117

St.LouisFingerprints,LLC 1115NewHallsFerryRd,STE109St.Louis,MO63033 HoursofOperation Monday–Friday9:00am–4:00pmSaturday–9:00amto1:00pmCLOSEDFORLUNCHFROM1:00PM–2:00PM TelephoneNumber(314)359-3117

St.LouisFingerprint,LLC625N.EuclidAve,STE307St.Louis,MO63108HoursofOperation Monday–Friday8:30am–4:00pmSaturday–8:30am–1:00pmCLOSEDFORLUNCHFROM1:00PM–2:00PM TelephoneNumber(314)359-3117

MBUUnionExtension

PrivateProbationServices27N.ChurchSt.Unit–AUnion,MO63084 HoursofOperation Monday–Thursday10:00am–3:00pmTelephoneNumber(636)789-4750

MBUFranklinCounty/PacificExtension

PrivateProbationServices27N.ChurchSt.Unit–AUnion,MO63084 HoursofOperation

Monday–Thursday10:00am–3:00pmTelephoneNumber(636)789-4750

JeffersonCollege/ArnoldExtension

PrivateProbationServicesofJeffersonCounty 411MapleSt.Hillsboro,MO63050HoursofOperation Monday–Thursday8:00am–8:00pmFriday–8:00am–4:00pm Saturday–ByappointmentonlyTelephoneNumber(636)789-4750

St.LouisFingerprints,LLC2716TelegraphRd,STE109St.Louis,MO63125 HoursofOperation Monday–Friday9:00am–4:00pmSaturday–9:00am–1:00pmCLOSEDFORLUNCHFROM1:00PM–2:00PM TelephoneNumber(314)359-3117

MineralAreaExtension

O.D.A.C.S.INC1122EastMainSt. ParkHills,MO63601HoursofOperation Monday–Thursday9:00am–2:00pmTelephoneNumber(573)431-6290

UPSStore4343614WalmartDr. Farmington,MO63640HoursofOperation Monday–Friday8:00am–6:00pmSaturday–9:00am–5:00pmTelephoneNumber(573)747-1460

Troy/WentzvilleExtension

GoinPostal 6311RonaldReaganDr.LakeSt.Louis,MO63367HoursofOperation Monday–Friday8:00am–6:00pmSaturday–9:00am–4:00pmTelephoneNumber(636)625-3080

GoinPostal 281W.VeteransMemorialPKWYWarrenton,MO63383 HoursofOperation Monday–Friday8:30am–6:00pm

Saturday–9:00am-2:00pmTelephoneNumber(636)456-1853

RendLakeExtension

Mt.VernonPoliceDepartment211N.10th St. Mt.Vernon,IL62864HoursofOperation CONTACTFORINFORMATIONTelephoneNumber(618)242-2727

IllinoisStatePolice1391S.WashingtonSt.DuQuoin,IL62832HoursofOperation CONTACTFORINFORMATIONTelephoneNumber(618)542-2171

JohnA.LoganExtension

CartervillePoliceDepartment126E.Illinois Carterville,IL62918HoursofOperation CONTACTFORINFORMATIONTelephoneNumber(618)985-4853

CarbondalePoliceDepartment501S.WashingtonSt.Carbondale,IL62901 HoursofOperation CONTACTFORINFORMATIONTelephoneNumber(618)457-3205

IllinoisStatePolice606E.CollegeCarbondale,IL62901HoursofOperation CONTACTFORINFORMATIONTelephoneNumber(618)529-6500

LewisandClarkExtension

AltonPoliceDepartment1700E.Broadway Alton,IL62002HoursofOperation CONTACTFORINFORMATIONTelephoneNumber(618)463-3505

WoodRiverPoliceDepartment111N.WoodRiverAve. WoodRiver,IL62095HoursofOperation CONTACTFORINFORMATION TelephoneNumber(618)251-3100