Employment Criminal Record Verification

EMPLOYMENT CRIMINAL RECORD VERIFICATION

Personal Information

Full Legal Name:

Date of Birth:    Driver's License / ID No.:

Position Information

Employment History (Most Recent First)

Education

References (Professional)

Criminal History Disclosure

Has the applicant ever been arrested, charged, pled guilty or no contest, or been convicted of a felony or misdemeanor?    Check one:    Yes    No
If Yes, provide full details below, including date(s), jurisdiction, offense, disposition, and sentencing information. If none, write "None".

Have you ever been subject to a restraining order, protective order, or similar court order that restricts your contact with another person?    Yes    No

Authorization and Release

I authorize the employer and its designated agents to obtain and review criminal history records, court data, driving records, and any other public records or investigative consumer reports that may pertain to my suitability for employment. I understand that such inquiries may include state, local, and federal records and that the employer may use a third-party consumer reporting agency to obtain this information.

I release from liability any person, institution, repo rting agency, employer, or court that provides such information. I understand that any false, misleading, or omitted information may be cause for denial of employment or immediate termination if employed. I further authorize my former employers, educational institutions, and references to disclose to the employer any and all employment-related information without restriction.

I consent to fingerprinting and submission of my fingerprints to appropriate agencies for the purpose of conducting a national criminal history records check if required for the position. I acknowledge that fingerprint-based checks may reveal arrests, charges, dispositions, and convictions.

Legal Notices and Policies

At-Will Employment: I understand that, if hired, my employment will be on an at-will basis unless otherwise expressly agreed in a separate written agreement signed by an authorized company representative. Either the employer or I may terminate the employment relationship at any time, with or without cause or notice.

Equal Opportunity: The employer provides equal employment opportunity to all applicants and employees. Criminal history will be considered only to the extent permitted by law and consistent with the employer’s policies and job-related requirements.

Applicant Certification and Authorization

I certify that all information provided in this form and any attachments is true and complete to the best of my knowledge. I understand that the employer may verify the information and conduct background and reference checks. I authorize the release of any information concerning my criminal history and employment records to the employer and its agents. I agree that a photocopy or electronic copy of this Authorization and Release shall be as valid as the original.

By signing below, I acknowledge I have read and understand this form, including the Criminal History Disclosure, Authorization and Release, and Applicant Certification. I understand that adverse employment decisions may be based on information obtained through the processes described herein, subject to applicable legal protections.

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