Jennifer Burns, Licensure Officer
 Dept. of Educational Theory and Practice
 MSU Billings, COE, Rm. 262
 1500 University Drive
 Billings, MT 59101
 Phone: 406-657-2293
 Fax: 406-657-2104
 jburns@msubillings.edu  	

Montana State University Billings Redissemination Request of 
Background Check Information 	
Candidate First Name	Candidate Middle Initial	Candidate Maiden Name	Candidate Last Name	
Street	City	State	Zip Code	
Telephone	Date of Birth       Month/Date/Year	Last 4 digits of SSN	
The undersigned requests and expressly authorizes Montana State University Billings to send a fax copy of the Criminal History Background Check Report to a Montana public school or school district or a unit of the Montana University System, an “authorized agency” as defined in federal law.  It is against FBI policy for background reports to be shared across state lines or with private institutions.  Reports being disseminated must be less than 2 years old.	

Background Check Report to be sent to _________________________________________________	
Recipient Address	
Recipient Telephone	Recipient Fax	
Recipient Contact Person	
Candidate Authorization:	
Signature	Date	
Montana State University-Billings reserves the right to deny the request
to disseminate any background check information	
- Request for MSU-Billings to share background information with other institutions -