Employment Fingerprint Application

EMPLOYMENT FINGERPRINT APPLICATION

This Employment Fingerprint Application authorizes the Employer and its designated agencies to collect fingerprints and submit them to authorized state and federal repositories for the purpose of criminal history record checks and identity verification in connection with employment consideration, hire, assignment, or continued employment. By completing and signing this form, the applicant consents to the collection, retention, and dissemination of fingerprint images and associated biographic information for employment-related background checks.

REQUESTING EMPLOYER / AGENCY

PERSONAL INFORMATION

Full Legal Name:

Previous or Other Names Used:

POSITION INFORMATION

PURPOSE OF FINGERPRINTING

Purpose (select applicable): Initial Hire Transfer Promotion Licensing/Certification Security Clearance Other:

PRIOR FINGERPRINTING / CRIMINAL HISTORY

Have you previously been fingerprinted by a law enforcement agency or employer for a background check? Yes No

Have you ever been convicted of a felony or misdemeanor? (Conviction will not necessarily disqualify you from employment.) Yes No

EMPLOYMENT HISTORY

Employer 1

Employer 2

EDUCATION

REFERENCES

Reference 1

Reference 2

Reference 3

LEGAL DISCLOSURES AND AUTHORIZATIONS

At-Will Employment: I understand that submission of this application and any fingerprint-based background check does not create an employment contract. If hired, I acknowledge that my employment will be at-will unless a written agreement states otherwise and is signed by the Employer's authorized representative.

Equal Opportunity: The Employer provides equal employment opportunity to all applicants without regard to race, color, religion, sex, national origin, age, disability, or any other protected characteristic as required by applicable law.

Authorization to Release Records: I hereby authorize the Employer, its agents, and authorized state or federal agencies to obtain, receive, and review any criminal history record information or related records that pertain to me. I authorize any law enforcement agency, court, educational institution, employer, or other entity to release such records to the Employer or its authorized representative.

Use and Retention: I understand that my fingerprints and resulting criminal history information may be retained or shared with other agencies as authorized by law for the purpose of future background checks or identification as permitted by statute.

Release and Liability Waiver: To the extent permitted by law, I release and hold harmless the Employer, its officers, employees, and agents, and any person or entity providing information, from any liability arising from the collection or dissemination of criminal history or other background information.

False Statements Penalty: I certify under penalty of perjury that the information provided on this form is true and complete. I understand that falsification, omission, or misrepresentation of information may be grounds for refusal to hire, or for disciplinary action up to and including termination if discovered after hire.

ADDITIONAL ADMINISTRATIVE INFORMATION

APPLICANT ACKNOWLEDGMENT

I certify that the information provided in this application is true and complete. I authorize the Employer to verify the information provided, to contact previous employers, educational institutions, and references, and to obtain criminal history record information. I understand that the Employer may make employment decisions based upon the results of the background check in accordance with applicable law.

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