To facilitate the verification of information contained within your employment, volunteer or contract for
services application, a criminal history check will be made with the Minnesota Department of Public
Safety, Bureau of Criminal Apprehension (BCA), local law enforcement agencies or other repositories of
criminal history data. The criminal history check may disclose both adult and juvenile records. The
information you are being asked to provide will be used to assure that an accurate inquiry of the records
systems can be made through all law enforcement records and data bases, in whatever format. You are
not legally obligated to provide this information, however we will be unable to allow you to continue in the
process without the data. The information requested in this authorization is classified as private under
the Minnesota Data Practices Act and will only be used for the purpose specified.
Check the appropriate box:
Contract Employee
Name: ______________
(Last) (Full First) (Full Middle)
Date of Birth: ______ / ____ / ______ Gender: Male Female
Month) (Day) (Year)
Race: African-American American Indian or Alaskan Eskimo Asian
Caucasian Native American or other Pacific Islander Hispanic or Latino
States of residence over the last ten years:
____________________________ , ___________________________ , __________________________
Specify any other names you have gone by or that you have been known by. State none, if
Specify your driver's license number and state of issue:
Number: State of Issue: ___________________
I authorize the City of Bloomington to conduct the records check as specified above. If returning or
continuing employment, volunteerism or contracted services, I authorize the City of Bloomington to
conduct an annual records check to determine my continued qualification.
Signature: Date: ______________________
I do not consent to a records check.
Signature: Date: ______________________
/p/forms/Background Check Authorization May 2013
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