Employment Criminal Clearance Form

EMPLOYMENT CRIMINAL CLEARANCE FORM

This form authorizes the employer to request and review criminal history information, to evaluate the information in connection with employment eligibility, and to maintain records as required by policy. All information provided will be treated as confidential and used solely for the purpose of processing employment clearance. Completion of this form is required for consideration and does not by itself constitute an offer of employment.

Personal Information

Full Legal Name:

Date of Birth:    Phone:    Email:

Position Information

Department:    Hiring Manager:    Proposed Start Date:

Full-Time    Part-Time    Temporary/Seasonal    Contract

Criminal History Disclosure

Have you ever been convicted of, or pleaded guilty or nolo contendere to, a criminal offense?   Yes    No

Are any criminal charges currently pending against you?   Yes    No

Have you ever been required to register as a sex offender?   Yes    No

Have any convictions been expunged, sealed, or otherwise set aside?   Yes    No

Employment History (most recent first)

Job Title:    From:    To:

Job Title:    From:    To:

Education

References (Professional)

Phone:    Email:

Phone:    Email:

Phone:    Email:

Legal Disclosures and Notices

At-Will Employment: If offered employment, either you or the employer may terminate the employment relationship at any time, with or without cause or notice, unless a written agreement signed by an authorized representative of the employer provides otherwise.

Equal Opportunity: The employer is an equal opportunity employer. Employment decisions are made on the basis of qualifications, merit and business need without regard to protected characteristics as defined by applicable law.

Authorization to Obtain Criminal History

I authorize the employer and its authorized agents and representatives to obtain criminal history records, fingerprint-based national checks, state and local criminal records, and other investigatory reports as required to determine my suitability for employment. I understand that this may include checks of law enforcement, correctional, and other governmental records.

I consent to the release of my criminal history and related information by courts, law enforcement agencies, prior employers, and other custodians of such records to the employer or its designated agent for employment purposes.

I understand and acknowledge that a conviction will not automatically disqualify me from employment. The employer will consider the nature of the offense, the date of conviction, rehabilitation, and the relevance of the offense to the duties of the position sought.

I authorize the employer to consider any records obtained and release the employer from any liability arising from such inquiries. I release all persons and entities supplying information from liability for providing such information.

Consent to specific checks (check all that apply):

State criminal history check    National criminal history check    Fingerprint-based background check

Applicant Certification and Release

I certify that all information provided on this form is true, correct and complete to the best of my knowledge. I understand that any omission, misstatement, or falsification of information may disqualify me from employment or may be grounds for immediate termination if discovered after hire.

By signing below I authorize the employer to contact prior employers, references, and educational institutions to verify information provided and to conduct the criminal history and other background checks described above. I understand that employment is contingent upon satisfactory completion of the required clearance checks.

Human Resources Use Only

Background Check Completed: Yes    No

Clearance Result:

HR Reviewer:    Review Date:

Sign Now