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: ______