Fillable Printable Criminal Background Check Form for Employment

Criminal Background Check Form for Employment

Rev. 09 July 2010

[Institution’s Name]

CRIMINAL BACKGROUND CHECK FORM

Human Resources

Disclosures: In processing your application for employment, or at any time during your employment period, the

[Institution’s Name] may obtain criminal records and/or a consumer report or investigative consumer report for

employment purposes, as authorized by state law and/or the Fair Credit Reporting Act (FCRA). The report may

include information as to my criminal record history. Should an investigative consumer report be requested, you

will have the right to obtain a complete and accurate disclosure of the nature and scope of the investigation

requested and a written summary of your rights under the Fair Credit Reporting Act.

With few exceptions, you are entitled on your request to be informed about the information [Institution’s Name]

collects about you. Under Sections 552.021 and 552.023 of the Texas Government Code, you are entitled to receive

and review the information. Under Section 559.004 of the Texas Government Code, you are entitled to have

[Institution’s Name] correct information about you that is held by us and is incorrect, in accordance with the

procedures set forth in UTS139. You may be required to correct/contest criminal background records with the source

of the record. The information that [Institution’s Name] collects will be retained and maintained as required by

Texas records retention laws (Section 441.180 et seq. of the Texas Government Code) and rules. Different types of

information are kept for different periods of time. Disclosure of your Social Security Number ("SSN") is required of

you in order for [Institution’s Name] to conduct a criminal background investigation, as mandated by Texas

Government Code, Sections 411.094 and 411.086. Further disclosure of your SSN is governed by the Public

Information Act (Chapter 552 of the Texas Government Code) and other applicable law.

THIS SECTION TO BE COMPLETED BY AN APPLICANT OR EMPLOYEE FROM WHOM A CRIMINAL

BACKGROUND CHECK IS REQUIRED

See [Cite Institutional HOP on Criminal Background Checks]

IMPORTANT: Print legibly using BLACK ink only. Fill out all information requested. If not applicable, enter N/A.

Falsification of any information on this form will void your application for employment and any actions based on it.

The information on the application for employment, including any attachments, is property of [Institution’s Name]

Administration.

Name:

_____________________________________________________________________________________________

________

Last First Middle Maiden

List any former names used:

__________________________________________________________________________________

Social Security #: ___________________________________ Driver's License - State and #:

______________________________

Ethnicity: Black (not Hispanic) ____ Asian/Pacific Islander ____ Hispanic ____

White (not Hispanic) ____ American Indian/Alaskan Native ____

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Rev. 09 July 2010

[Institution’s Name]

CRIMINAL BACKGROUND CHECK FORM

Human Resources

Gender: Male ____ Female ____ Date of Birth (MM/DD/YY): ___________________ Height:

______________

List ALL residency information since the age of 17 – dates of residency, city, and state, beginning with your most current. Please

account for out of the country residency as well. If additional space is needed, please attach a separate sheet.

From (MM/YY) To (MM/YY) City State County/Country

No ____ Yes ____ Do you have any criminal convictions since age 17 or older or any deferred

adjudications where the final disposition is still pending (i.e. the original charge has not

been dismissed)?

If yes, list year(s) of conviction(s) and nature of offense(s) and penalty(ies). If additional space is needed, attach a separate sheet.

Year Nature of Offense Penalty

I hereby authorize [Institution’s Name] to obtain and/or its agent to obtain and furnish information to [Institution’s Name] related to my criminal

background. I consent to providing my fingerprints if required in connection with the criminal background check. I hereby release [Institution’s Name] and

all its agents and employees, the law enforcement agency, and all employees of law enforcement agencies furnishing information from all liability resulting

from the furnishing of this information to [Institution’s Name]. I certify that the statements made by me on this form and in connection with my application

whether on this form or not, are true, complete and correct to the best of my knowledge and belief and I understand that any misstatement, falsification, or

omission of information shall void my application and be grounds for refusal to hire or, if hired, termination. I certify that I will report in writing any

charges or conviction, excluding misdemeanor offenses punishable only by fine, occurring after the date of this application to the [Institution’s Name]

Office of Human Resources. If circumstances require that an offer be made before the completion of an investigation, the offer is contingent on the

completion of a satisfactory criminal background investigation. I understand that any false statements made herein will void my Application for

Employment and any actions based on it.

_____________________________________________________________________________________________

______________

Applicant/Employee Signature Date

THIS SECTION TO BE COMPLETE BY THE EMPLOYING DEPARTMENT

Applicant/Employee status: Faculty ______ Staff ______ Student ______

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Rev. 09 July 2010

[Institution’s Name]

CRIMINAL BACKGROUND CHECK FORM

Human Resources

Posting Number: ____________________________________ Posted Job Title: _________________________________________

Department Name: __________________________________________________Department Phone Number: (ext) ____________

Department Contact: ________________________________________ Signature: ____________________ Date: ______________

Send this completed form to [Institution’s Name] Human Resources ([Fax Number])

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