JUNIOR BUSO

FREI GASPAR DA MADRE DE DEUS, 926

APTO 202 BLOCO 05
CURITIBA, PA 81050590

APPLICANT RIGHTS & CONSENT TO FINGERPRINT NOTICE

As required by 28 CFR § 50.12, you are advised that your fingerprints will be used to check the
criminal history records of the Federal Bureau of Investigation and the Montana Department of
Justice for the sole purpose of applying for professional licensure. Any resulting criminal history
record will be retained for this purpose only and will not be disseminated outside of the Montana
Department of Labor & Industry and related licensing board or program.
A Privacy Act Statement further explaining authority, principal purpose and routine use by the FBI
of your information is included on the following page.

CHANGE, CORRECT, OR UPDATE RECORD

Procedures for you to obtain a change, correction, or update to your criminal history record are set
forth in Title 28, C.F.R. § 16.30 - 16.34.
Our office will notify you if a disqualifying criminal offense is found in your criminal history record
and give you a reasonable opportunity to challenge or correct the information, or decline to do
so, before making a licensure decision.
If we notify you of a disqualifying conviction in your criminal history record, you may contact board
or program licensing staff at the Business Standards Division of the Department of Labor & Industry
to obtain a copy of your criminal history record. You can view your criminal history record in person,
have it mailed to you, or sent to you by the State of Montana File Transfer Service. For security
reasons, the criminal history record cannot be emailed to you.
If, after review, you believe your criminal history record is incorrect or incomplete and wish to
change, correct, or update the alleged deficiency, you should apply directly to the law enforcement
agency that contributed the questioned information. Alternatively, you may send your challenge
directly to the FBI. The FBI will then forward your challenge to the law enforcement agency that
contributed the question information requesting the agency to verify or correct the challenged entry.
Upon receipt of an official communication from that agency, the FBI will make any necessary
changes in accordance with the information supplied by that agency. Information regarding this
process may be obtained www.fbi.gov/services/cjis/identity-history-summary-checks.
Within 10 calendar days of the date of receiving the results of the criminal history record, you
must notify the board or program licensing staff if you have challenged your record by providing a
copy of the correspondence you have submitted as referenced above. If the licensing board or
program has not received a copy of such correspondence within 10 calendar days, licensing staff
will schedule a disposition on the issuance of your license based on the record in its possession.

BSD 3.8 Rev. 08/12/2019

 Privacy Act Statement
The Montana Department of Labor & Industry, Business Standards Division is required by
federal law to provide you this privacy act statement. This statement is also located on the back
of the FD-258 fingerprint card.
“Authority: The FBI’s acquisition, preservation, and exchange of fingerprints and associated
information is generally authorized under 28 U.S.C. 534. Depending on the nature of your
application, supplemental authorities include Federal statutes, State statutes pursuant to Pub. L.
92-544, Presidential Executive Orders, and federal regulations. Providing your fingerprints and
associated information is voluntary; however, failure to do so may affect completion or approval
of your application.
Principal Purpose: Certain determinations, such as employment, licensing, and security
clearances, may be predicated on fingerprint-based background checks. Your fingerprints and
associated information/biometrics may be provided to the employing, investigating, or otherwise
responsible agency, and/or the FBI for the purpose of comparing your fingerprints to other
fingerprints in the FBI’s Next Generation Identification (NGI) system or its successor systems
(including civil, criminal, and latent fingerprint repositories) or other available records of the
employing, investigating, or otherwise responsible agency. The FBI may retain your fingerprints
and associated information/biometrics in NGI after the completion of this application and, while
retained, your fingerprints may continue to be compared against other fingerprints submitted to
or retained by NGI.
Routine Uses: During the processing of this application and for as long thereafter as your
fingerprints and associated information/biometrics are retained in NGI, your information may be
disclosed pursuant to your consent, and may be disclosed without your consent as permitted by
the Privacy Act of 1974 and all applicable Routine Uses as may be published at any time in the
Federal Register, including the Routine Uses for the NGI system and the FBI’s Blanket Routine
Uses. Routine uses include, but are not limited to, disclosures to: employing, governmental or
authorized non-governmental agencies responsible for employment, contracting, licensing,
security clearances, and other suitability determinations; local, state, tribal, or federal law
enforcement agencies; criminal justice agencies; and agencies responsible for national security
or public safety.” Eff. 03/30/2018
By signing below, I acknowledge that I have received a copy of the above
Applicant Rights & Consent to Fingerprint Notice and Procedure to Change, Correct, or
Update Record, and Privacy Act Statement and that I consent to provide and use my
fingerprints for the stated purpose.
Applicant Acknowledged Online
07/27/2022
Signature: Date:

Applicant JUNIOR BUSO

Name: incor
Please Print Legibly

Directions to Applicant: Return a signed copy of this document to the Department of Labor &
Industry and maintain a copy for your own records.

BSD 3.8 Rev. 08/12/2019