Employment Criminal Record Check

Employment Criminal Record Check Authorization and Agreement

WHEREAS

WHEREAS Employer Name: seeks to obtain and evaluate criminal history information as part of pre-employment screening and ongoing employment suitability determinations;

WHEREAS Applicant Name: desires to be considered for employment and is willing to provide authorization to the Employer and its authorized agents to obtain criminal records as permitted by law;

NOW, THEREFORE, in consideration of the Employer's evaluation of the Applicant's suitability for employment, the parties agree as follows.

Parties and Contact Information

Identification

Date of Birth:    Driver's License No.:    Issuing State:

Last 4 digits of Social Security Number:

Scope of Work — Background Check Services

The Employer (or its authorized agent) may obtain criminal history information, including but not limited to national and state criminal databases, state and local court records, sex offender registry checks, and law enforcement records. The scope, jurisdictions searched, and methods used shall be described below.

Authorization and Consent

I, the undersigned Applicant, authorize the Employer and its designated agents to obtain criminal history information about me for the purpose of evaluating my application for employment and, if applicable, continued employment. I understand that this authorization includes inquiries of public and private records and databases and may include fingerprint-based checks where required.

I consent to criminal history checks and related verifications.    Fingerprinting as required for jurisdictions checked.

I understand that a criminal conviction will not automatically disqualify me from employment; the Employer will consider the nature, severity and recency of any conduct, and whether it bears a demonstrable relationship to the duties and responsibilities of the position sought.

Payment Terms

Fee for background check services: USD.

If the Applicant is responsible for payment and fails to remit the required fees when due, the Employer may delay processing of the background check until payment is received. Late payments may accrue the late fee stated above.

Term and Termination

Authorization Effective Date:    Authorization Expiration Date:

Either party may terminate this authorization upon written notice to the other party. Notice period (days): ; termination does not affect the Employer's right to retain previously obtained information as permitted by law.

Confidentiality and Use of Information

All criminal history information obtained pursuant to this Authorization will be maintained confidentially and used solely for legitimate employment purposes. The Employer will store such information in secured files and disseminate it internally only to persons with a demonstrated need to evaluate the Applicant's employment suitability. The Employer will not disclose criminal history information to third parties except as required by law or with the explicit written consent of the Applicant.

Representations, Warranties and Acknowledgements

The Applicant represents and warrants that all information provided in this form is true, correct and complete to the best of the Applicant’s knowledge. The Applicant acknowledges that any material misrepresentation or omission may constitute grounds for refusing employment or for termination if employed.

Governing Law

This Agreement and the Applicant's authorization shall be governed by and construed in accordance with the laws of the State of: without regard to conflict of law principles.

Entire Agreement

This document constitutes the entire agreement between the Employer and the Applicant with respect to the subject matter herein and supersedes all prior agreements, understandings and representations, whether oral or written. Any amendment must be in writing and signed by both parties.

Acknowledgement and Certification

By signing below, the Applicant certifies under penalty of perjury that the information provided is true and complete, and expressly authorizes the Employer and its designated agents to obtain criminal history information as described above. Applicant further acknowledges receipt of any separate disclosure required by law and understands the Employer's procedures for notification and dispute of adverse results.

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