Can the form be signed electronically

Yes. Electronic signatures meet ESIGN Act requirements (15 U.S.C. ch. 96) and UETA in most states. Ensure the signer consents to electronic records when the transaction is consumer-facing.

Do I have to disclose sealed or expunged records

Requirements vary. Some licensing boards still require disclosure of expunged or sealed matters; check the requester's instructions and state law before omitting any record.

What if I discover an error after submitting

Notify the requester promptly and provide corrected details and supporting documentation. Organizations should have a correction and remediation process documented.

Is notarization required

Not usually for employment screenings, but some licensing applications or state forms require notarized or witnessed signatures; verify with the requesting agency.

How long will background checks take

Typical vendor turnaround is 3 to 10 business days, depending on jurisdictions searched and record retrieval complexity.

How is sensitive data protected

Use platforms that employ TLS 1.2/1.3 in transit and AES-256 at rest, and execute a BAA when storing or transmitting HIPAA-protected data.

Electronic Signature
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Criminal History Disclosure Form

Criminal History Disclosure Form

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

CRIMINAL HISTORY DISCLOSURE FORM AND CONSENT AGREEMENT

Applicant Name: Date of Birth:

Address:

Contact Phone: Email:

Recitals

WHEREAS, the Applicant seeks to provide services to or obtain a position with the Organization and understands that the Organization requires disclosure of certain criminal history information as a condition of employment, placement, licensing, or contracting;

WHEREAS, the Applicant agrees to provide full and accurate information regarding past criminal proceedings and to authorize the Organization to obtain criminal history records and related information from authorized agencies and repositories; and

WHEREAS, the Organization will use such information only in accordance with applicable law and the confidentiality provisions set forth in this Agreement.

Scope of Disclosure

Criminal History Questions

Have you ever been convicted of a felony or misdemeanor? Yes No

If yes, provide full details (offense, jurisdiction, date, disposition)

Are there any pending criminal charges against you? Yes No

If yes, describe the nature of the charge, jurisdiction, and current status

Have you ever been arrested without conviction or had a record expunged or sealed? Yes No

If yes, provide details including jurisdiction and order information

Authorization and Consent

By checking the box below, the Applicant authorizes the Organization and its designated agents to obtain criminal history records, fingerprints, court records, and other relevant information from local, state, and national repositories for the purpose of evaluating eligibility for employment, placement, licensing, or contracting.

Applicant consents to criminal history and background check Applicant consents to fingerprinting as required Applicant authorizes release of records to the Organization

Payment Terms

Processing Fee Amount Payment Schedule Late Fee

Term and Termination

Effective Date: Termination Date (if applicable):

Notice Period for Termination

Confidentiality

All criminal history information received by the Organization under this Agreement shall be treated as confidential and retained in secure files. Disclosure of such information shall be limited to individuals with a legitimate need to know and as required by law. The Organization shall implement reasonable administrative and technical safeguards to protect such information from unauthorized disclosure.

Governing Law

This Agreement shall be governed by and construed in accordance with the laws of the State selected by the Organization for contractual disputes. The parties submit to the exclusive jurisdiction of the courts of that State for any action arising out of this Agreement.

Entire Agreement

This document constitutes the entire agreement between the Applicant and the Organization with respect to criminal history disclosure and supersedes all prior oral or written communications, representations, or agreements. Any amendment must be in writing and signed by both parties.

Certification and Acknowledgment

I certify under penalty of perjury that the information provided on this form is true, complete, and correct to the best of my knowledge. I understand that willful falsification or omission of material facts is grounds for denial of employment, termination, or other legal action. I acknowledge that the Organization may rely on the information provided herein and that it may verify the information through investigative means.

Applicant Additional Remarks

Applicant:

By:

Date:

Organization Name:

By:

Date:

What the Criminal History Disclosure Form Is and when it's used

The Criminal History Disclosure Form is a standardized document used to record an individual's past criminal convictions, pending charges, and relevant adjudications for employment, licensing, contracting, or volunteer screening. It typically asks an applicant to disclose convictions, the dates and jurisdictions, and whether legal rights have been restored. The form is intended to collect factual background information that a reviewer can verify against public records or background checks and may be combined with consent language for criminal background checks or fingerprinting when required by the requesting organization.

Why organizations and applicants rely on this disclosure

A clear Criminal History Disclosure Form helps organizations meet regulatory screening obligations, make informed risk decisions, and document consistent hiring or licensing practices while providing applicants the opportunity to explain past matters.

Which people and organizations commonly use this form

Use depends on statutory requirements and organizational policy; some roles require both the disclosure form and a separate criminal background check authorization.

Employers conducting pre-employment screening in safety-sensitive or regulated roles
Licensing boards for professions such as healthcare, childcare, and finance
Volunteer organizations and nonprofits for positions involving vulnerable populations

Who can sign and certify the form

Applicant

The individual whose history is being disclosed must sign and date the form; electronic signature is acceptable where allowed under ESIGN (15 U.S.C. ch. 96) and applicable state law.

Authorized Reviewer

An authorized hiring manager, licensing official, or HR representative signs to acknowledge receipt and to document the date of review and any follow-up steps required by policy.

Essential sections to include on a professional disclosure form

A well-structured Criminal History Disclosure Form balances clarity for the individual and sufficient detail for reviewers. Key sections reduce ambiguity and support consistent decision-making.

Identifying Information

Full legal name, other names used, date of birth, and current address to allow accurate record matching when verifying public records.

Scope Statement

Clear instructions on what convictions or charges to report (e.g., felonies, misdemeanors, juvenile adjudications) and any look-back or exception rules.

Disclosure Table

Structured rows for offense description, date, jurisdiction, disposition, and case or docket number for each item disclosed.

Applicant Explanation

Space for context, rehabilitation steps, or court-ordered diversion that the applicant can use to explain circumstances.

Consent & Certification

Optional authorizations for criminal background checks and a certification statement that the information is true under penalty of perjury when required.

Signature and Date

Signature block with signer name, date, and an indication whether an electronic signature was used; include witness or notary fields if state law requires.

Step-by-step: completing and submitting the form

Follow these steps to complete the Criminal History Disclosure Form accurately and to ensure timely processing.

01

1 Fill identification: Enter legal name, DOB, and current address.
02

2 List incidents: Record each charge, date, jurisdiction, and disposition in separate rows.
03

3 Provide explanation: Attach a short statement if context or rehabilitation is relevant.
04

4 Sign and submit: Sign the form, date it, and follow submission instructions from the requester.

How organizations can configure a digital workflow

Design a consistent intake workflow so disclosures are collected, routed, and stored with proper access controls and audit logs.

Field	Configuration
Identity Verification	Email + SMS OTP or document upload for stronger matching
Conditional Fields	Show explanation box only if 'Yes' to prior conviction
Reviewer Routing	Route to HR or compliance by role-based rules
Audit Trail	Enable timestamp, IP, and action history for each submission

Where to send or file the completed form

Send the completed disclosure according to the requester's instructions; digital submission often follows a standardized routing sequence.

Submit to Requester: Attach signed form to application portal or email the designated compliance address
Background Check Vendor: Provide consent and release to allow authorized vendor to verify listed records
Licensing Authority: For professional licenses, upload to the board's secure submission portal as instructed
Retention Repository: Store a copy in HR or licensing records with restricted access

Digital signing and technical distribution considerations

Ensure the chosen solution can produce an audit trail, support BAA for HIPAA-covered uses, and export signed copies for offline retention.

Supported Formats: PDF and DOCX with embedded signature fields
Integrations: Connectors for HRIS, applicant tracking, and cloud storage like Salesforce and Google Workspace
Security: TLS 1.2/1.3 in transit and AES-256 at rest

Typical timelines: processing and disclosure deadlines

Timelines vary by purpose; licensing boards and employers may set submission windows or require updated disclosures at periodic intervals.

Initial Application:

Submit with application or within the timeframe requested by the organization

Follow-up Verification:

Background vendors commonly return results within 3–10 business days

Periodic Recheck:

Many employers require annual or biennial rechecks for sensitive roles

Correction Window:

Notify requester within 10 business days if you discover an error

Expungement Update:

Provide documentation promptly when records are sealed or expunged

Key milestones from submission to final decision

A typical processing timeline tracks submission, verification, review, decision, and record retention stages.

01

Submission Received

Form accepted and timestamped by intake system

02

Identity Verification

Verification of applicant identity and matching to records

03

Criminal Record Check

Third-party background vendor returns report

04

Decision & Notification

Organization documents decision and notifies the applicant

Common mistakes to avoid when completing the form

Providing incomplete dates or missing jurisdiction details that prevent accurate record matching
Failing to disclose sealed or expunged matters where board rules still require disclosure
Using nicknames or initials instead of full legal name, causing false negative or positive matches
Omitting signature date or using inconsistent dates that raise verification questions

Consequences of incorrect, incomplete, or false disclosures

Employment Termination: Material misrepresentation can be grounds for dismissal

Licensing Sanctions: Licensing boards may deny, suspend, or revoke credentials

Civil Liability: Incorrect disclosures can expose applicants to legal claims

Criminal Penalties: False statements on official forms can lead to prosecution in some contexts

Background Mismatch: Incomplete details increase risk of inaccurate matches and delays

Re-Application Delays: Correcting records or providing proof of expungement can extend processing time

Real-world examples of how the form is used

Illustrative scenarios show how disclosure and review can affect decisions in different settings.

Healthcare Licensing Review

A nurse applicant disclosed a 10-year-old misdemeanor

Board requested certified court disposition
After review and proof of rehabilitation the board issued a conditional license with monitoring requirements and documentation retained in the file.

Nonprofit Volunteer Screening

A volunteer disclosed a past conviction for property theft

Organization required a background check and role-based restrictions
The volunteer was approved for non-sensitive duties with supervised access and records kept for three years.

Practical tips to improve accuracy and speed

Apply consistent procedures to reduce errors and accelerate review while protecting applicant privacy.

Use clear scope language

Define exactly which convictions or arrests must be reported and include any statutory exceptions to reduce ambiguity during applicant completion.

Prefer structured fields

Use separate fields for date, jurisdiction, disposition, and case number to improve automated matching and reduce manual review time.

Support electronic ID

Include identity-verification steps such as SMS OTP or document upload when matching records to reduce false positives.

Document remediation

Include instructions for applicants to submit expungement or sealing documents and a defined process for record correction.

How the Criminal History Disclosure differs from related forms

Compare closely related documents so users choose the correct form for each purpose.

Criteria	Criminal History Disclosure	Background Check Authorization
Primary Purpose	self-reported history	consent to vendor search
Signature Required
Contains Consent	sometimes	always
Use Case	candidate disclosure and explanation	vendor-initiated record retrieval

Sample eSignature vendor pricing and capability snapshot

When collecting and signing Criminal History Disclosure Forms electronically, compare pricing and feature availability. Vendor plans and features vary; check vendor documentation for details.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day free trial	Varies by vendor	Varies by vendor	Varies by vendor	Varies by vendor
Bulk Send	Yes (plan-dependent)	Yes (plan-dependent)	Yes (plan-dependent)	Yes (plan-dependent)	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes (BAA required)	Yes (BAA available)	Yes (BAA available)	No	No

Frequently asked questions about the Criminal History Disclosure Form

Answers to common issues when completing, submitting, or verifying a disclosure form.

Need help? Contact support

Can the form be signed electronically
Yes. Electronic signatures meet ESIGN Act requirements (15 U.S.C. ch. 96) and UETA in most states. Ensure the signer consents to electronic records when the transaction is consumer-facing.
Do I have to disclose sealed or expunged records
Requirements vary. Some licensing boards still require disclosure of expunged or sealed matters; check the requester's instructions and state law before omitting any record.
What if I discover an error after submitting
Notify the requester promptly and provide corrected details and supporting documentation. Organizations should have a correction and remediation process documented.
Is notarization required
Not usually for employment screenings, but some licensing applications or state forms require notarized or witnessed signatures; verify with the requesting agency.
How long will background checks take
Typical vendor turnaround is 3 to 10 business days, depending on jurisdictions searched and record retrieval complexity.
How is sensitive data protected
Use platforms that employ TLS 1.2/1.3 in transit and AES-256 at rest, and execute a BAA when storing or transmitting HIPAA-protected data.

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