STAFFORD MUNICIPAL SCHOOL DISTRICT

CONSENT TO PERFORM CRIMINAL HISTORY BACKGROUND CHECK IN COMPLIANCE WITH

THE FCRA (FAIR CREDIT REPORTING ACT)

 

Date:  _________________________

 

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Last Name     First Name Middle Initial

                                                                                                                                                                                 

__________________________________________________

Maiden and / or Other Last Names Used

 

___________________________________   ________________________________ ______________    
City* County*     State*

 

______________________          __________________ __________________ __________________
Date of Birth**    Social Security Number**   Sex**  Race**

                                                                                         

 

I, _________________________________, am an applicant for employment with Stafford Municipal School District and have been advised that as a part of the application process, the employer conducts a criminal history background check.  I do hereby consent to the employer use of any information provided during the application process in performing the criminal history check. The employer has informed me that I have the right to review and challenge any negative information that would adversely impact a decision to offer employment. In addition, I have been informed that I will have a reasonable opportunity to clear up any mistaken information reported within a reasonable time frame established within the sole discretion of the employer. Under the fair Credit Reporting Act, I have been advised that upon request I will be provided the name, address, and telephone number of the reporting agency as well as the nature, substance and source of all information.

 

*AS SHOWN ON THE ORIGINAL APPLICATION

**TO BE USED ONLY FOR CRIMINAL HISTORY SEARCHES, AND NOT A PART OF THE PERSONNEL FILE.

 

The following are my responses to questions about my criminal record history (if any) with descriptions to any question with a YES answer:

 

1. Have you ever been convicted or plead guilty before a court of any federal, state, or municipal criminal offense? (Excluding minor traffic violations) YES     NO

                                                                                                                                                                                                                            

If YES, please provide an explanation below:

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2. Have you ever-received deferred adjudication or similar disposition for any federal, state or municipal criminal offense?     YES     NO

                                         

If YES, please provide an explanation below:

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__________________________________________________________________________________________________________________________

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 3. Have you ever-received probation or community supervision for any federal, state, or municipal criminal offense?    YES     NO

                                                 

If YES, please provide an explanation below:

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4. Have you ever been convicted of any criminal offense in a country outside the jurisdiction of the United States?   YES     NO

                                                     

If YES, please provide an explanation below:

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5. As of the date of this authorization, do you have any pending criminal charges against you?    YES     NO

                                                                                    

If YES, please provide an explanation below:

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THIS  SECTION  IS TO BE  USED  TO LIST   ALL COUNTIES  AND  STATES OF RESIDENCE  SINCE  AGE 18 OR HIGH SCHOOL GRADUATION. 

YOU MUST BE SPECIFIC ABOUT DATES OF RESIDENCE.

 

CITY/TOWN

COUNTY

STATE

DATES FROM

TO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I   HEREBY   CERTIFY   THAT   ALL   INFORMATION    PROVIDED   IN    THIS   AUTHORIZATION    IS   TRUE,   CORRECT   AND   COMPLETE. I  UNDERSTAND  THAT   IF  ANY   INFORMATION   PROVES  TO  BE  INCORRECT OR  INCOMPLETE  THAT GROUNDS   FOR  THE  CANCELING OF  ANY  AND  ALL  OFFERS   OF  EMPLOYMENT  WILL  EXIST  AND  MAY  BE  USED  AT  THE  DISCRETION OF  THE  EMPLOYER.      

     

 

Applicant (Print Name) ____________________________________________________________________

 

Applicant Signature___________________________________________________________________  Date __________________________