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Attachment A University of California Santa Barbara Fingerprint Authorization Form Submit to Human Resources Note Applicants must bring identification to their LiveScan appointment such as a driver s license or passport. Date of Birth Legal Name of Employee to be Fingerprinted Employee ID Payroll Title/Working Title Department Name 1. Purpose of Background Check UCSB Person being fingerprinted is a Volunteer Title Code Student Non-Employee 2. Attachment A University of California Santa Barbara Fingerprint Authorization Form Submit to Human Resources Note Applicants must bring identification to their LiveScan appointment such as a driver s license or passport. Date of Birth Legal Name of Employee to be Fingerprinted Employee ID Payroll Title/Working Title Department Name 1. Purpose of Background Check UCSB Person being fingerprinted is a Volunteer Title Code Student Non-Employee 2. Services Requested Calif* DOJ Background Check 32. 00 Required for all employees in critical positions. Calif* DOJ and FBI Background Check 49. 00 who have lived in a U*S* state other than California since the age of 18. 3. Payment Information Note If this is a staff position where successful completion of a background check is a condition of continued employment the employee s department is responsible for the cost of fingerprinting. Will employee be paying the cost of fingerprinting Yes No Department If Yes the 24 Rolling Fee will be recharged to the department. By signing below you are authorizing a* The above employee to be fingerprinted as part of the background check process. b. Payment. Authorized Signature Print/Type Name Title Department Code e*g* CHEM Phone Extension Date Account Number Loc-Account-Fund-Sub or BARC to be recharged 4. Contact Information Department Contact for Results 03/19/12 Employment/Background Checks/Fingerprint Authorization Form. Attachment A University of California Santa Barbara Fingerprint Authorization Form Submit to Human Resources Note Applicants must bring identification to their LiveScan appointment such as a driver s license or passport. Date of Birth Legal Name of Employee to be Fingerprinted Employee ID Payroll Title/Working Title Department Name 1. Date of Birth Legal Name of Employee to be Fingerprinted Employee ID Payroll Title/Working Title Department Name 1. Purpose of Background Check UCSB Person being fingerprinted is a Volunteer Title Code Student Non-Employee 2. Purpose of Background Check UCSB Person being fingerprinted is a Volunteer Title Code Student Non-Employee 2. Services Requested Calif* DOJ Background Check 32. 00 Required for all employees in critical positions. Services Requested Calif* DOJ Background Check 32. 00 Required for all employees in critical positions. Calif* DOJ and FBI Background Check 49. 00 who have lived in a U*S* state other than California since the age of 18. Calif* DOJ and FBI Background Check 49. 00 who have lived in a U*S* state other than California since the age of 18. 3. Payment Information Note If this is a staff position where successful completion of a background check is a condition of continued employment the employee s department is responsible for the cost of fingerprinting.

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