REQUEST, AUTHORIZATION, CONSENT,
AND
RELEASE
FOR BACKGROUND INFORMAT
IO
N
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
Co
ll
ege 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.
1
· (
The information I
ha
ve given
in
my employment application, interviews, and/or relat
ed
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 sha
ll
be
subject
to immediate termination.
I understand that
in
the event a conviction for a felony or any crime
invo
lving moral turpitu
de
is
found that
the procedures established for the Board
of
Trustees policy concerning criminal background checks will
be fo
ll
owed .
I have read and completely understand this
re
lease.
Applicant's Signature: _ _
_____________
_
Date:
Applicant's Name
(P
lease
print):---------------------
- -
Applicant's
Address:--
-
------------------
- - -
----
Applicant's
Birthday:----------------------
- -
--
-
Applicant's Driver's License Number:
___________________
_ _ _
Applicant's Driver's License State:
-----------------------
Revised March 2019
