Conviction Disclosure

Have you ever been convicted of any violation(s) of law, including moving traffic violations? □ Yes □ No If yes, please provide the following information (attach additional pages if necessary):

• Offense/Violation:

• Date of Conviction: ___

• Location (City/State): ___

• Disposition/Sentence: ___

Disclosure & Authorization

□ I understand that Kentucky State University may obtain consumer reports, investigative consumer reports, criminal history checks, employment verifications, education verifications, and/or other background information about me as part of its consideration of my application, volunteer service, or employment, and at any time during my service or employment if permissible by law.

□ I authorize KSU and its designated agents or consumer reporting agencies to obtain such information for employment, volunteer, or academic purposes. I understand that this information may include, but is not limited to, verification of education, employment history, professional licenses, motor vehicle records, criminal records, and other public records.

□ I release KSU, its employees, officers, and agents, as well as any person or organization providing information, from any and all liability related to furnishing such information.

□ I acknowledge that I have received a copy of the “Summary of Your Rights Under the Fair Credit Reporting Act” (FCRA).

Certification of Background Check Information

By signing below, I certify that the information provided on this form is true, complete, and correct to the best of my knowledge. I understand that providing false or misleading information may result in disqualification from employment or volunteer service, or termination if already engaged.

Printed Name: ___

Signature: _____ Date: _____