OFFICE OF HUMAN RESOURCES ACADEMIC SERVICES #241 | 400 EAST MAIN STREET FRANKFORT, KY 40601 | (502) 597-6667 KYSU.EDU
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 (Required; Enter N/A if None) Last Name
Middle Name
Last Name
First Name
Other Names Used (e.g., maiden, aliases):
Date of Birth: ___ / ___ / ___ Social Security Number: ___ / ___ / ___
Other Names Used (e.g., maiden, aliases
Date of Birth
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Social Security Number
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Driver's License Number & State:
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Driver’s License Number & State
Current Address:
Current Address
City _____ State _____ Zip:
State
Zip
City
Phone Number: Email Address:
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
Revised: September 2025