Employee Fingerprinting Registration

Employee Fingerprinting Registration

Personal Information

Full legal name:

Date of birth:   Place of birth:

Gender:   Race/Ethnicity:

Height:   Weight:   Eye color:   Hair color:

Position / Employer Information

Anticipated start date:   Employment status: Full-time Part-time Contractor

Fingerprinting Details

Reason for fingerprinting:

Ink card    Live Scan / Electronic    Other:

Appointment date:   Time:

Employment History (most recent first)

From:   To:

From:   To:

Education

Major/Field:   Graduation date:

Professional References

Legal Disclosures

At-Will Employment: I understand that submission of this registration and any offer of employment does not alter the at-will nature of my employment relationship, if applicable. Either I or the employer may terminate the employment relationship at any time, with or without cause or notice, unless otherwise provided in a written agreement signed by an authorized representative.

Equal Opportunity: The employer is an equal opportunity organization. Decisions regarding fingerprinting, hiring, promotion, and retention will be made without regard to protected characteristics as defined by applicable law.

I acknowledge receipt of the At-Will Employment statement.

I acknowledge receipt of the Equal Opportunity statement.

Consent, Authorization and Certification

By signing below, I authorize the employer and the requesting agency to collect my fingerprints for the purpose of a criminal history records check and related identity verification. I authorize the release of any criminal history, arrest, conviction, and other records obtained through fingerprint-based searches to the employer and the requesting agency for employment-related background review.

I understand that fingerprints and results may be retained in state or national criminal history repositories in accordance with applicable law and that these records may be used for future background checks if permitted by law. I understand I may be asked to provide additional identifying information and that I have the right to challenge the accuracy of any record obtained.

I consent to fingerprinting and authorize release of fingerprint-based records as described above.

Yes    No

Applicant Certification: 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 false statements or omissions may be grounds for denial of fingerprinting services or termination of employment where applicable.

Additional Information (Optional)

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