Criminal Conviction Check Authorization



HR USE ONLY Background Checks Required: FORMCHECKBOX Criminal and Sex Offender FORMCHECKBOX Credit FORMCHECKBOX Driving FORMCHECKBOX CDL(Please select all that apply)As a component of North Carolina Central University’s ongoing security initiatives and to ensure a continuous environment of safety for our students, staff and visitors, University policy requires that a background check be conducted for all staff and faculty, unpaid volunteers, interns, visiting scholars and other individuals engaged by campus departments in programs that serve or involve contact with minors.Background checks will be used only to evaluate candidates/employees for employment purposes and will not be used to discriminate on the basis of race, color, national origin, religion, sex, disability, age, veteran’s status, gender identity or sexual orientation. Background checks related to the protection of minors served by University programs must be processed at least annually for University staff, faculty, or volunteers with ongoing involvement in such programs, regardless of previous background checks that may have been conducted.NOTE: Your social security number is required by the University and the background check vendor to conduct a residence history and criminal conviction background check consistent with University policy. If you choose not to disclose your social security number, you will not be considered for employment.CANDIDATE INFORMATIONLEGAL NAME - FIRSTMIDDLEMAIDENLAST FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????All other name(s) by which you have been known: FORMTEXT ?????SOCIAL SECURITY (SSN)DATE OF BIRTHSEXRACEGENDER FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX MALE FORMCHECKBOX FEMALE FORMCHECKBOX International Applicants – Check here if you do not have a Social Security Number.NORTH CAROLINA DRIVERS LICENSE #EXPIRATION DATEOUT OF STATE DRIVERS LICENSE #I HAVE AN OUT-OF-STATE DRIVER’S LICENSE THAT HAS BEEN VALID LAST 12 MONTHS. FORMCHECKBOX YES FORMCHECKBOX NOIF YES, PROVIDE THE NUMBER BELOW AND SELECT ISSUING STATE FOR THE NEXT FIELD.ISSUING STATE FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????CURRENT APPLICANT RESIDENCE PHYSICAL ADDRESSCITYZIPCOUNTYSTATECOUNTRY FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????PREVIOUS ADDRESSES (PROVIDE ALL ADDRESSES FOR PAST SEVEN (7) YEARS)USE ADDITIONAL PAGE(S) IF NECESSARYADDRESSCITYCOUNTYSTATECOUNTRYFROM DATETO DATE FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????INTERNATIONAL ASSIGNEESHAVE YOU LIVED OR WORKED OUTSIDE NORTH CAROLINA OR THE UNITED STATES?PLEASE LIST THE COUNTRY, STATE, COUNTY, CITY, DATES AND THE NAME(S) USED DURING THE REPORTED PERIODS.COUNTRYSTATECOUNTYCITYFROM DATETO DATENAME(S) USED (IF DIFFERENT FROM ABOVE) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????CRIMINAL HISTORY Have you ever been convicted of any unlawful offense other than a minor traffic violation? FORMCHECKBOX Yes FORMCHECKBOX NoThis includes DUI/DWI, worthless checks, violations of local ordinances or state statues that resulted in a fine or incarceration, misdemeanors, felonies, etc. Guilty verdicts, guilty pleas, prayers for judgment (PJC), and “no-contest” please must be included unless the convictions have been expunged from your record.If yes, list below the date(s), locations (county(ies), state(s) and specific crime(s). Use an additional sheet is necessary. A previous conviction will not automatically disqualify you from employment. However, failure to provide complete and accurate information is considered “falsification,” and your application may be removed from consideration. If falsification occurs and you are currently employed, you may be subject to disciplinary action up to and including termination of employment. If you are unsure of you conviction history please verify prior to answering.Note: Pending criminal charges may delay the University’s employment decision until after a verdict in the case has been rendered. DATELOCATION (COUNTY AND STATE)CONVICTIONS AND CRIMES FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????DEPARTMENT INFORMATIONPosition TitleDepartmentCollege/Division FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????CONTACT NAMETELEPHONEEMAIL FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????AUTHORIZATION TO CONDUCT BACKGROUND CHECKI acknowledge that I have carefully read and understand the Background Check Authorization and Release Form. I hereby certify that all information provided on this Authorization is true and complete to the best of my knowledge and belief. I understand that any misrepresentation or false statement made within the application or related documents which are deemed relevant material may result in North Carolina Central University not hiring or terminating my employment. I understand that electronic submission of my Authorization establishes my consent to the University’s verification of all information contained in this Authorization, including obtaining a consumer report for the purpose of employment from a Consumer Reporting Agency. I understand that by admitting to a conviction for any unlawful offense, I will not be automatically disqualified from consideration for employment with NCCU. I also understand that false or misleading information or documentation, or an omission, or the failure to include and disclose all relevant information will result in rejection of my application. Action leading up to and including termination of employment and/or criminal prosecution can occur. If hired, I understand the University complies with State law and will be required to terminate me if false or misleading information is given in order to meet the requirements for the position. FORMTEXT ????? FORMTEXT ?????Candidate Name TYPED or PRINTED Candidate SIGNATUREDate ................
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