I have been informed and acknowledged that on April 13, 2016 the Alabama Community College System Board
of Trustees adopted Policy 623.01 requiring criminal background checks for all new and current employees.
By signing this authorization, I hereby authorize the Alabama Community College System or its designee, to
conduct criminal reference searches for felony and misdemeanor convictions at the statewide and national levels
of every jurisdiction where I currently reside or where I have previously resided during the past seven years;
national sex offender registry searches and a search of my driving record.
I understand that I may voluntarily consent to the use of my social security account number for the purpose of
conducting a criminal background check. I further understand that my voluntary consent to use my social
security account number is being requested for purposes of conducting a criminal background check, pursuant
to the authority of the Alabama Community College System Board of Trustees policy regarding criminal
background checks. I understand that neither the Alabama Community College System nor any employing
authority within the Alabama Community College System will deny me any right, benefit or privilege provided
by law because of my refusal to voluntarily consent to the use of my social security account number for the
limited purpose of conducting a criminal background check pursuant to the Alabama Community College
System Board of Trustees policy regarding criminal background checks.
______I voluntarily consent to the use of my social security account number for the limited purpose of
conducting a criminal background check. Social Security #
______I do not consent to the use of my social security account number for the limited purpose of conducting a
criminal background check.
______I consent to the use of my driver’s license number to be used for the limited purpose of conducting a
review of my driving history.
_____ I do not consent to the use of my driver’s license number for the limited purpose of conducting a review
of my driving history.
The information I have given in my employment application, interviews, and/or related resumes and documents
is true, complete, and accurate.
I understand and agree that if employed, and/or during any period of employment, any false statements,
misrepresentations of facts, or omission made by myself become known, my employment shall be subject to
immediate termination.
I understand that in the event a conviction for a felony or any crime involving moral turpitude is found that the
procedures established for the Board of Trustees policy concerning criminal background checks will be followed.
Signature: Date:
Name (Please Print):
First Middle Maiden Last
Address:
Street City State Zip
Applicant’s Date of Birth: Phone number:
Driver’s License #: State Issued:
Email:
REQUEST, AUTHORIZATION, CONSENT, AND RELEASE
FOR BACKGROUND INFORMATION
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