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BACKGROUND CHECK INFORMATION FORM

Kentucky State University (KSU) conducts background checks on employees, volunteers, and other individuals as required by law and University policy. The information you provide below will be used solely for the purpose of obtaining background check reports in accordance with the Fair Credit Reporting Act (FCRA) and applicable state and federal regulations.

Completion of this form is required to process your background check.

Personal Information:

First Name

Middle Name

Last Name

Middle Name Last Name

(First Name)

(Required; Enter N/A if None)

Other Names Used (e.g., maiden, aliases): ___

Other Names Used (e.g., maiden, aliases

Date of Birth: ___ / ___ / ___ Social Security Number: ___ / ___ / ___

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Date of Birth

Social Security Number

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Driver's License Number & State: ___

Driver’s License Number & State

Current Address: ___

Current Address

City _____ State _____ Zip: _____

City

State

Zip

Phone Number: ___ Email Address: ___

Phone Number

Email Address

State Law Requirement

□ I understand that state law requires both a state and national criminal history and background check as a condition of employment. I further understand that a conviction reported below will not automatically disqualify me from employment.

I understand that state law requires both a state and national criminal history and background check as a

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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):

Have you ever been convicted of any violation(s) of law, including moving traffic violations

Offense/Violation:

Offense/Violation

Date of Conviction: ___

Date of Conviction

Location (City/State): ___

Location (City/State

Disposition/Sentence: ___

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 understand that Kentucky State University may obtain consumer reports, investigative consumer reports

□ 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 authorize KSU and its designated agents or consumer reporting agencies to obtain such information for

□ 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 release KSU, its employees, officers, and agents, as well as any person or organization providing

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

I acknowledge that I have received a copy of the “Summary of Your Rights Under the Fair Credit Reporting

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: ___

Printed Name

Signature: _____ Date: _____

Signature

Date

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Summary of Your Rights Under the Fair Credit Reporting Act (FCRA)

The Fair Credit Reporting Act (FCRA) is a federal law that gives you certain rights when an employer, school, or other organization requests a background check report about you.

Your Key Rights

You must be told if a background check will be used.

Before requesting a background report, an employer must notify you in writing and get your written permission.

You must receive a copy of your rights.

This summary is provided so you understand what protections you have under the FCRA.

You can say yes or no.

You must give written consent before an employer or organization can obtain your background check (with some exceptions for ongoing employment in certain industries).

You have the right to know what's in your file.

You may request a free copy of your background report from the company that prepared it.

You must be notified if information in your report is used against you.

If an employer plans to deny you employment, volunteer service, or another opportunity based on your report, they must:

Give you a “pre-adverse action notice” with a copy of the report and a summary of your rights.

Give you time to dispute or correct inaccurate information before making a final decision.

You have the right to dispute inaccurate or incomplete information.

If you find errors, you can dispute them with the background check company. They must investigate and correct mistakes.

You have the right to seek damages for violations.

If your rights under the FCRA are violated, you may be able to pursue legal remedies.

More Information

For more details about your rights under the FCRA, visit the Federal Trade Commission (FTC) at: www.consumerfinance.gov/learnmore.