Employee Live Scan

EMPLOYEE LIVE SCAN

This Employee Live Scan form authorizes the requesting employer or agency to obtain fingerprint-based state and national criminal history information about the named applicant. Completion of the Live Scan and submission of fingerprints constitutes authorization for the transmission and use of criminal history information for employment suitability determinations as permitted by law.

Requesting Agency / Employer

Applicant Personal Information

Full Legal Name:

Date of Birth:    Place of Birth (City, State):

Social Security Number (last 4 digits):    Driver's License / ID No.:

Primary Phone:    Email Address:

Position Information

Department:    Reporting Manager:

Anticipated Start Date:    Salary / Pay Rate:

Employment History (Most Recent)

Title:    Dates Employed: From To

Employment History (Prior)

Title:    Dates Employed: From To

Education

Graduation Date:    Additional Certifications:

Professional References

Legal Disclosures and Notices

At-Will Employment: Employment with the requesting employer, if offered, is at-will unless otherwise provided in a written agreement signed by an authorized representative of the employer. Nothing in this form creates a contract of employment for any specific duration.

Equal Opportunity: The requesting employer is an equal opportunity employer. Decisions regarding employment are made without regard to protected characteristics except where a bona fide occupational qualification or applicable law permits differentiation.

Authorization & Consent for Live Scan and Background Check

I, the undersigned, authorize the taking of my fingerprints and the release of state and national criminal history record information to the requesting employer or agency for employment suitability determination, licensing, and other lawful purposes specified above. I understand that the information obtained will be used only for authorized purposes and that I may be required to provide identifying data to aid in record retrieval.

I certify that the information I have provided on this form is true and correct to the best of my knowledge. I understand that making false statements or omitting material information may result in denial of employment or termination. I authorize the employer and its agents to investigate my background, including contacting former employers, educational institutions, licensing authorities, and references, and to obtain copies of any records relevant to my suitability for the position.

I acknowledge notice that criminal record information received may be considered in making an employment decision; a conviction is not an automatic bar to employment and will be considered in relation to the duties and responsibilities of the position. I further acknowledge that I have been given the opportunity to provide additional information or context regarding any criminal history.

I authorize fingerprinting and background check as described above.
I authorize the employer to contact previous employers and educational institutions for verification.
I release from liability any person or institution providing information to the requesting employer in good faith.

Fee, Operator & Transaction Information (for Live Scan Operator Use)

Fee Paid By:    Amount Paid:

Transaction or Control Number:    Date of Scan:

Applicant Certification

I certify under penalty of perjury that the information provided on this form is true and correct. I understand that a criminal history check will be performed using my fingerprints and that I may request a copy of any criminal history record used in an adverse employment determination. I acknowledge that I have read and understand the information and consent to the background investigation as described herein.

Notice: The information requested on this form is required to process fingerprint submissions and background checks. The requesting agency will retain this form as part of its hiring file in accordance with applicable record retention policies and privacy laws.

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