Criminal Record Disclosure Statement

Criminal Record Disclosure Statement

This Criminal Record Disclosure Statement (the "Statement") is entered into as of Date: by and between Requesting Party Name: with Mailing Address: ("Requesting Party") and Applicant Name: Date of Birth: Applicant Address: ("Applicant").

Recitals

WHEREAS, the Requesting Party requires an accurate disclosure of the Applicant's criminal history for purposes of evaluation in connection with employment, volunteer services, licensing, contracting, or other official purposes specified by the Requesting Party; and

WHEREAS, Applicant is willing to disclose any criminal convictions, criminal charges, pending matters, or adjudications and to authorize the Requesting Party to obtain relevant records and verify information provided herein; and

WHEREAS, the parties desire to set forth the terms on which such disclosures and authorizations shall be made.

NOW, THEREFORE, in consideration of the mutual covenants herein contained, the parties agree as follows:

1. Definitions

For purposes of this Statement, the following definitions apply: "Criminal Record" means convictions, guilty pleas, no contest pleas, deferred adjudications, juvenile adjudications where not sealed, arrests, charges, indictments, or other criminal proceedings; "Conviction" means a judgment of guilt by plea or verdict, or the imposition of a criminal sentence.

2. Applicant Disclosure

Applicant shall disclose below all convictions, pleas, pending charges, deferred adjudications, and other criminal matters as defined above. Applicant must list each matter and provide a factual description including date, jurisdiction, charge, disposition, and sentence or penalty. If Applicant has no relevant criminal matters to disclose, check the first box and proceed to Section 3.

I have no criminal convictions, pending charges, or adjudications to disclose.

If disclosing, check applicable categories (one or more):
Conviction Pending charge/Arrest Deferred adjudication Sealed or expunged matter (describe below)

3. Authorization to Obtain Records

Applicant hereby authorizes the Requesting Party, its agents, representatives, and contractors to obtain Criminal Records and any other background information about Applicant from courts, law enforcement agencies, correctional institutions, and other third parties. Applicant expressly authorizes those entities to disclose such records to the Requesting Party and waives any statutory or common-law privacy claims to the extent necessary to permit such disclosure.

Applicant further authorizes the Requesting Party to use photocopies or electronic copies of this document to obtain records and acknowledges that a facsimile or electronic copy of this authorization shall have the same force and effect as the original.

4. Applicant Representations and Warranty

Applicant represents and warrants that all information provided in this Statement is true, complete, and correct to the best of Applicant's knowledge. Applicant understands that omission or falsification of information may constitute grounds for denial of employment, denial of a license, termination of services, or other adverse action by the Requesting Party, and may subject Applicant to civil or criminal penalties where applicable.

5. Use, Confidentiality, and Retention

Information obtained pursuant to this Statement shall be used solely for the stated purposes in the Recitals. The Requesting Party will treat disclosed information as confidential to the extent required by law, retain records only as necessary for legitimate business or legal purposes, and limit access to authorized personnel. Nothing in this paragraph shall prevent the Requesting Party from disclosing information if required by legal process.

6. Expunged, Sealed, or Set-Aside Matters

Applicant must disclose matters notwithstanding any expungement, sealing, or set-aside order unless a statute expressly permits nondisclosure. If Applicant claims a matter has been expunged, sealed, or set aside, Applicant must attach certified documentation and identify the court and case number in the detailed disclosure above.

7. Release and Indemnification

Applicant releases and forever discharges the Requesting Party, its agents, employees, and contractors from any liability or claims arising from the release, collection, use, or dissemination of Criminal Records obtained pursuant to this Statement, except for willful misconduct or gross negligence. Applicant agrees to indemnify the Requesting Party for claims arising from Applicant's misrepresentations in this Statement.

8. Notices

All notices required under this Statement shall be in writing and delivered to the addresses set forth below. Notice is effective upon personal delivery or three (3) days after deposit in the United States mail, postage prepaid.

9. Governing Law; Severability; Entire Agreement

This Statement shall be governed by and construed in accordance with the laws of the state specified for the Requesting Party's principal place of business without regard to conflict of laws principles. If any provision of this Statement is held invalid or unenforceable, that provision shall be modified to the minimum extent necessary to make it enforceable, and the remaining provisions shall remain in full force and effect. This Statement constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior agreements and understandings, whether written or oral.

10. Amendments; Waiver; Counterparts

Any amendment to this Statement must be in writing and signed by both parties. No waiver of any provision shall be valid unless in writing and signed by the party granting the waiver. This Statement may be executed in counterparts and by electronic signature, each of which shall be deemed an original and all of which together shall constitute one and the same instrument.

11. Applicant Certification

By signing below, Applicant certifies under penalty of perjury that the information provided in this Statement is true, complete, and correct. Applicant acknowledges receipt of a copy of this Statement and understands the rights and obligations set forth herein.

Sign Now