Form Revised 8/22/16
Cumberland County Schools
Disclosure/Authorization for
Criminal Background Check
INSTRUCTIONS: Please fill form out in its entirety. Incomplete forms will delay processing.
Current Legal
Last Name:
Current Legal
First Name:
Current Legal
Middle Name:
Maiden/
All other names:
Social Security Number:
Sex:
Female Male
Date of Birth:
_____/______/_________
Driver’s License #:
State:
Ethnic Group:
ASIAN (including Pacific Islander)
BLACK (non-Hispanic)
HISPANIC
INDIAN (including Alaskan Native)
WHITE (non-Hispanic)
Are you a current Cumberland County Schools employee? YES NO
Have you previously applied? YES NO
Signature: ________________________________________________________________________________ Date: ______________________
HUMAN RESOURCES USE ONLY:
Residency Information: List last ten years, beginning with most current (NO PO BOXES)
Dates
ADDRESS
CITY
STATE
ZIP CODE
FROM
MM/YY
TO
MM/YY
Position(s) Applied for: (include all position that you want to be considered for)
My signature below authorizes Cumberland County Schools (CCS) to obtain information about me from a consumer reporting agency for the purposes of employment, volunteering, student
teaching/intern, outside service provider, contract services, etc. This information may be obtained at any time after the receipt of my authorization and throughout my term of service
and/or consideration. The types of information that may be obtained include but are not limited to social security number verification, sex offender registry checks, criminal records checks,
inmate record searches, motor vehicle records checks, and court record checks. The consumer report will be obtained from Background Investigative Bureau, LLC (BIB), located at 9710
Northcross Center Court, Huntersville, NC 28078, phone number 1-877-439-3900. I hereby authorize any law enforcement agency, administrator, local state or federal agency to furnish any
and all background information requested by BIB, additional third party organizations acting on behalf of CCS, and/or CCS itself. I certify that the information given by me in this application is
true and complete. I understand that any misrepresentation, falsification or omission will be sufficient cause for cancellation of this application or dismissal from employment if you have
been hired. It is understood that this application and all other pre-employment data become property of CCS. I understand that my date of birth, sex and ethnic group will not be used to
discriminate against me in violation of any law. I agree that a copy of this authorization shall be valid as the original. (Revised 8/1/15)
E-mail:
click to sign
signature
click to edit
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