VSUPD: Please return results to: Human Resources V.P.A.A. Student Employment
VALDOSTA STATE UNIVERSITY
APPLICANTS CONSENT TO BACKGROUND INVESTIGATION
(revised 07/01/08)
I hereby authorize Valdosta State University Police Department and the hiring agent(s) of Valdosta State University for the purpose of employment consideration to receive any information regarding: criminal history, education verification, sexual offender status, motor vehicle record, employment references, drug screening, or credit record check, where applicable, and which may involve public record or various federal, state or local agencies. This list is not all inclusive.
Please use black or blue ink only.
Full Name ______
Address ______
City ______State ______Zip ______
Date of Birth______Social Security Number ______
Place of Birth: City ______County ______State/Province ______Country ______
Driver’s License Number ______State of Issue ______
Sex: Male Female Race: Black Asian Native American White Hispanic Other (specify) ______
Physical Description: Height ______Weight ______Eye Color ______
INSTRUCTIONS – Please Read
Read the following carefully and answer truthfully, if you have been convicted of a crime, you may not be automatically disqualified from consideration for employment. GIVING FALSE OR INCOMPLETE INFORMATION IS SUFFICIENT CAUSE TO DISQUALIFY YOU FROM EMPLOYMENT. If you are not sure of the court disposition of a case, list all other information requested.
Have you EVER been convicted of a crime, paid a fine, forfeited a bond, been sentenced (by a judge) to perform community service, pled no lo contendere (no contest), pled guilty, been given a suspended sentence, or been sentenced to jail or prison time? (Include DUIs, but DO NOT include minor traffic offenses, juvenile cases, cases sealed or expunged by a court, or case completed under the First Offender Act.)
Yes No DO NOT ASSUME CHARGES OR CONVICTIONS HAVE BEEN REMOVED.
If the answer is YES to any of the above, list all information requested below. (Please use additional sheets if necessary.)
Charge/Offense Date Arresting Agency/Location Court Disposition
______
______
Having read all of this form, I give Valdosta State University my consent to conduct the investigation and release all persons from any and all liability with respect to said investigation. The information will be disclosed only to Human Resources employees and persons(s) responsible for making hiring decisions.
Signature ______Date ______
Notary Public ______My commission expires ______
Department ______Department Contact ______
Form revised 7/1/08
For Criminal Background Checks:
This information is current and valid as of the date of review:
Date Checked: ______Report Reviewed by: ______
Dept:______Title:______
For Credit Report Checks:
Eligible Ineligible
This information is current and valid as of the date of review
Date Checked: ______Report Reviewed by: ______
Dept:______Title:______
Other Background Checks Appropriate to the Position:
Type:______
Eligible Ineligible
This information is current and valid as of the date of review
Date Checked: ______Report Reviewed by: ______
Dept:______Title:______
Additional Information ______:
______
______
For V.P.A.A./Human Resource’s Use:
Date Received: ______Eligible ______Ineligible
Date Applicant Notified: ______
Date Employing Department Notified: ______V.P.A.A./HR Initials: ______