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.
(First Name) Middle Name (Required; Enter N/A if None) Last Name
Other Names Used (e.g., maiden, aliases):
Date of Birth: ___ / ___ / ___ Social Security Number: ___ / ___ / ___
Driver's License Number & State:
City _____ State _____ Zip:
Phone Number: Email Address:
□ 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.