Consent To Perform Criminal History/background Check Form printable pdf download

CONSENT TO PERFORM CRIMINAL HISTORY/BACKGROUND CHECK

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First Name ________________________ Middle Name ___________________ Last Name _______________________

Street address_____________________________ City____________________ State___________ Zip Code_______

Maiden name(s) or other name used in any other records____________________________________________________

*Date of Birth (MM/DD/YYYY)_____________________________________ *Gender__________________________

*Social Security Number______________________________________ *Race_________________________________

Driver’s License State of Issue______________________________ DL Number________________________________

*Required information, to be used for criminal history checks

I, ____________________________________, am an applicant for employment/volunteerism with Beaufort County Schools and

have been advised that as a part of the application process, the district conducts criminal history background checks. I do hereby

consent to the district use of any information provided during the application process in performing the criminal history checks. The

district has informed me that I have the right to review and challenge any negative information that would adversely impact a decision

to offer employment/volunteerism. In addition, I have been informed that I will have a reasonable opportunity to clear up any

mistaken information reported within a reasonable time frame established within the sole discretion of the district. Under the Fair

Credit Reporting Act, I have been advised that upon request I will be provided the name, address and telephone number of the

reporting agency as well as the nature, substance and source of all information.

The following are my responses to questions about my criminal history (if any).

ALERT: With the exception of minor traffic offenses or infractions, it is imperative that you list any and all convictions for any

offenses, including but not limited to: DWI, underage possession of alcohol, assault, worthless check, or any other offenses. It is

imperative that you list any offenses for which you have been convicted, plead guilty or no contest to, or received a prayer for

judgment, or received “deferred prosecution” which is not yet finalized or expunged.

Failure to disclose any of the above could result in denial of approval.

1. ____YES ____NO Have you ever been convicted or entered a plea guilty or nolo contendere (no contest) to any

criminal offense other than a minor violation (such as speeding). If yes, please provide details below.

State: _____________________ County: ______________________________ Date of Offense: ________________

Details of conviction: ____________________________________________________________________________

______________________________________________________________________________________________

2. ____YES ____NO Have you ever received deferred adjudication/prosecution or similar disposition that was not

completed and resulted in a conviction for any federal, state or municipal offense (other than an offense for which all

records pertaining to the offense have been expunged)? If yes, please provide details below.

State:_____________________ County:________________________________ Date of Offense: _______________

Details of offense:_______________________________________________________________________________

______________________________________________________________________________________________

Please be sure to complete page 2 of this form!

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Consent To Perform Criminal History/background Check Form