Background Check Information Form
| PART I: APPLICANT INFORMATION | |||
| Position Applied For: | |||
|---|---|---|---|
| Interviewing Official: | |||
| First Name: | Other Names Used: | ||
| Middle Name: | |||
| Last Name: | |||
| Address: | |||
| City/ST/Zip | |||
| SSN: | Date of Birth: | ||
| Driver's License: | Issuing State: | ||
| Name on Driver's License: | |||
| Contact Phone No: | E-mail: | ||
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 Answer these questions for all positions requiring the use of a vehicle: Have your driving privileges ever been revoked or suspended?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Answer these questions for all positions requiring the use of a vehicle: Have your driving privileges ever been revoked or suspended?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