01/06/2016
BACKGROUND AND REFERENCE RELEASE AUTHORIZATION
I am an applicant for employment with Wichita State University (hereinafter “University”) and I recognize and understand the need for
the University to be fully informed as to my fitness for employment, including education, academic credentials, background information
and prior employment record.
In specific reference to my application for employment, I hereby certify that, to the best of my knowledge and belief, all information
provided by me to the University throughout the search and selection process is true, correct and complete. I acknowledge and
understand that providing false, inaccurate or misleading information will be sufficient and complete justification to reject my application
and make me ineligible for future consideration for employment with Wichita State University or termination from employment, if the
hiring decision was based or premised, in any way, on false, inaccurate or misleading information provided by me or on my behalf.
I acknowledge and understand that representatives of the University may choose to contact individuals other than those persons whom
I have or will indicate as my references and I hereby authorize and consent to such contact. I am also advised and understand that
offers of employment are contingent upon satisfactory criminal background check (as required by Kansas Board of Regents Policy),
educational credential verification, and, in some cases, a credit check. In the event a criminal background check (or credit report) is
deemed to require consideration of an adverse decision regarding my employment with Wichita State University, I will be provided with
a copy of the report[s] and a description in writing of my rights under the federal Fair Credit Reporting Act.
In consideration of the opportunity to be considered for employment with the University, I hereby specifically consent to and authorize a
criminal background check (and/or credit report), and do hereby authorize all past and current employers, academic institutions, and
other appropriate persons or entities to release to the University and its representatives, information regarding me, my employment
history and/or my education, including transcripts and other information considered to be education records under the Family
Educational Rights and Privacy Act of 1974, that will reasonably assist the University in considering my abilities, experience and
qualifications for the position being sought.
This authorization and release is valid from the date set out below and shall remain valid for a period of ninety (90) days following the
date of signature. A copy of this authorization and release is as valid as the original.
I understand that in the event I accept a contingent offer of employment with the University, I will be provided a link by email to the
Validity website where I will make application for a background check through the services of Validity, the company performing
background checks for the University.
Applicant’s E-mail address:
Applicant’s Phone #
myWSU ID#
(if applicable) ………
Signature
Printed First Name Printed Last Name
Date of Signature
REQUIRED:Informationinthisboxtobecompletedbythehiringorganization:
Positionname: Positionnumber:
Hiringorg#: Hiringorgname:
Positionfundedby: GUfunds RUfunds
IfRUfundedposition–pleaseprovide: Billingorg# Billingfund#
Positionfilledby: Search SearchWaiver:
EmergencyHire
TypeofHire: BenefitsEligible Grad/Student Lecturer
Volunteer Temporary
PriorStateService: Yes No
Driver’sLicenseCheckNeeded: Yes No
SearchChair/HiringManagerName: Ext.
