Background Check Information Form
| PART I: APPLICANT INFORMATION |
| Position Applied For: | |
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| Interviewing Official: | |
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| First Name: | | Other Names Used: |
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| Middle Name: | | |
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| Last Name: | |
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| Address: | |
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| City/ST/Zip | |
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| SSN: | | Date of Birth: | |
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| Driver's License: | | Issuing State: | |
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| Name on Driver's License: | |
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| Contact Phone No: | | E-mail: | |
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PART II: DISCLOSURE OF VIOLATIONS OR CONVICTIONS
I understand that state law requires 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.
Have you ever been convicted for any violation(s) of law, including moving traffic violations? ☐ Yes ☐ No
If YES, please provide the following:
(For additional convictions use plain paper. Include all information listed above.)
Answer these questions for all positions requiring the use of a vehicle: Have your driving privileges ever been revoked or suspended? ☐ Yes ☐ No
If yes, list here:
Answer these questions for all positions requiring the use of a vehicle: Have your driving privileges ever been revoked or suspended? ☐ Yes ☐ No
The facts as stated on this form are true and correct. I understand that, if employed, false statements on this or any university form may cause my immediate dismissal.
\qquad\qquad Date: _____
Signature of Applicant: ___
Background Check Information 12 12 2018