Fill and Sign the Consent Form PDF

CRIMINAL HISTORY CHECK CONSENT FORM I, ____________________________ , hereby authorize { Insert Name of Company } to obtain information pertaining to any charges and/or convictions I may have had for violation of municipal, county, state or federal laws. This information will include, but not be limited to, allegations regarding and convictions for crimes committed upon minors and will be gathered from any law enforcement agency of this state or any state or federal government, or from third-party providers of information originally obtained from law enforcement or court records. I understand that I will be given an opportunity to challenge the accuracy of any information received that appears to implicate me in criminal activities. To facilitate this challenge, I will be told the nature of the information and the agency from which it was obtained. It will be my responsibility to contact that agency. I further understand that until { Insert Name of Company } receives notification from that agency clearing me, my application will be deferred. As an applicant for a { Insert Name of Company } staff position, I hereby attest to the truthfulness of the representations I have made. Except as I have disclosed, I have not been found guilty of, or entered a plea of nolo contendre or guilty to any offense similar to those listed on the application. Further, other than for the offenses I have disclosed, I have not had a finding of delinquency or entered a plea of nolo contendre or guilty to a petition of delinquency under the juvenile laws of this state or of any other state for any acts similar in nature to those listed on the application. I further attest that I have not been judicially determined to have committed abuse or neglect of a child; nor do I have a confirmed report of child abuse or neglect or exploitation which has been uncontested or upheld administratively under the laws of this or any other state. I understand that I must be truthful and, if any statement I have made is found to be false, I will be denied a { Insert Name of Company } or, if already accepted, terminated from my { Insert Name of Company } position. _______________________________________ Date: ______________ (Signature of the Applicant) Full Name of the Applicant: ___________________________ Date of Birth: __________ Sex: __________ Race: _________ Social Security Number: ______________________________ Driver's License Number: _____________________________ State of Issuance: __________ Date of Expiration: _______________________________