Directions
1. Enter your name, department name for your primary position, and the name
of your Administrative Supervisor for your primary position.
2. Complete the entire form, providing all appropriate information related to the
charge(s) or conviction(s).
3. Sign and date form. Electronic signatures are accepted.
4. Save the completed PDF as a new file.
5. Email the new file to HR-Support@star.lcc.edu.
Name _________________________________ Department_______________
Administrative Supervisor _____________________________________________
___ I am currently charged with the following felony (do not list misdemeanor or
civil infraction charges): _________________________________________.
The charge is pending in ____________________________________ court.
___ I have been convicted of, or pled guilty or no contest to, the following
criminal offense(s): ____________________________________________.
The charges were decided in ________________________________ court.
My electronic signature certifies that the above information is correct as of the
date listed below.
Signature____________________________ Date__________________
