Last Name:
First Name: MI:
Address Line1:
Address Line2:
City:
State: Zip: Country:
Home Phone:
(use format nnn-nnn-nnnn)
Cell Phone:
Email:
(use format xxx@xxx.com)
Position applied for:
Salary admin plan for applicant:
Age at time of completion of this form:
Note: If applicant is under the age of 18, then the Juvenile Criminal Background Check Consent form must be signed by a parent/guardian, and returned to Records Management.
Note: The hiring official listed will be the person who is contacted by Records Management at the completion of the Criminal Background Check.
Hiring Official:
Hiring Department:
Phone:
E-mail:
Note: This form must be completed and submitted to Records Management prior to the applicant being offered employment. Applicant must be made aware that a criminal background check will be conducted, and the applicant's employment status will be determined after the completion of the aforementioned background check. There is no cost to the applicant for the processing of the background check.