University of West Georgia
Human Resources Office
Background Investigation Questionnaire
In connection with my application for employment (including contract for services), I am giving Sterling Infosystems, Inc.,
a consumer reporting agency, permission to perform a consumer report (to include, but not limited to, credit, MVR, or
criminal background check) on my past history, now and on future dates or an investigation consumer report may be
made and forwarded to University of West Georgia. I understand that providing my email to complete a release, or, by
signing this release, does not constitute automatic employment with University of West Georgia.
Please print your full name and email address below:
*Name: ________________________ ________________________ ________________________
Last First Middle
*Email: _____________________________________________________________________________
*By providing your email address, you will receive an email to complete your background investigation electronically.
Position Applied For: _________________________________________________________________________
Division/Department: ________________________________________________________________________
Department Point of Contact: __________________________________________________________________
Have you ever been convicted or are there any charges now pending against you by Federal, State, or other law-
enforcement authorites for any violation of any federal law, state law, county or municipal law, regulation or ordinance?
(Do not include anything that happened before your sixteenth birthday. Do not include minor traffic violations for which
a fine of $35.00 or less was imposed. All other convictions must be included even if they were pardoned.)
A criminal conviction will not necessarily preclude an offer of employment. The position applied for, the nature of the
offense, the time since its occurrence and other factors will be considered. However, failure to disclose a criminal
conviction on this questionnaire will be considered falsification of application materials and will preclude an offer of
employment.
Yes No
List all convictions to include date, location, and agency involved:
___________________________________ ___________________________________
Print Full Name Signature of Full Name
click to sign
signature
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