6
AUTHORIZATION TO DO CRIMINAL BACKGROUND CHECK
In connection with your application, you hereby authorize John A. Logan College to obtain and furnish
reports from various agencies regarding your criminal history to John A. Logan College for employment purposes.
The amended Fair Credit Reporting Act (1997) requires that we inform you that a background check may
be conducted as part of our employment screening process. The main objective of the background check is to
verify information you provided on your application/resume or during the interview process. In the event that any
report from an outside agency is utilized in making an adverse decision regarding your potential employment, JALC
will provide you with an address to obtain a copy of the information or report and a description in writing of your
rights under the law prior to making such an adverse employment decision. We will provide you with the
disclosure within five (5) business days of the date on which we receive your written request.
I hereby authorize and request all circuit courts and their officers, officials and employees, state
agencies and their officials and employees, local and state law enforcement agencies, federal law enforcement
agencies, International law enforcement agencies having criminal information relevant to my background for
employment purposes, to release any and all information upon John A. Logan College’s request. I further
release, hold harmless and agree to indemnify any of the foregoing from any and all liability, injury, damages,
claims, demands, causes of action, suits, judgments and executions, whether sounding in tort, contract, equity
or law, which I and my heirs, personal representatives, assigns, executors and administrators now have, or in
the future may have, against any of the foregoing for providing the requested reports to John A. Logan College.
PLEASE TYPE OR PRINT LEGIBLY
Last Name: ____________________________ First
Name: ________________ Middle Name: __________
Other names known by (including maiden): _________________________________________________________
Address: ___________________________________________________________________________________
Street/P.O. Box, City, State, Zip Code, County
Date of Birth Driver’s License
tate
S
Male Female
Home Addres
ses for the Past 7 Years:
treet Address City
tate County Dates Mo/Year
Previous Felon
y/Misdemeanor Criminal Convictions? Yes No
Charge/Conviction
County
tate Dates Mo/Year
By my signature below, I hereby authorize JALC to obtain my criminal history. I hereby state that I have read this document in detail and
clearly understand the terms and rights that I have granted to JALC for the collection and release of the aforementioned information.
Signature
of Applicant ____________________________________________ Date ______________
A conviction record will not necessarily be a bar to employment, and factors such as age at the time of the offense, seriousness and nature
of the violation, and rehabilitation will be considered.
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signature
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