ReappointmentApplicationandPersonalBackgroundCheckConsentForm

650 W Easterday Avenue •Sault St Marie,MI•49783•Telephone(906) 635-2121•Fax :(906) 635-6669

Name:

FirstMiddleInitialLast

StreetAddress:

City:State:Zip:

Home Number:WorkNumber: FacsimileNumber:_E-­mail: Employer:

AcriminalrecordscheckmustbeconductedasaconditionforappointmentasapublicofficialservingontheboardofapublicschoolacademyauthorizedbyLake Superior StateUniversity.ThisconsentdoesnotauthorizenorwillLake SuperiorStateUniversityconductaconsumercreditcheck.

Informationrequestedonthispagewillbeusedtoconductacriminalrecordscheckandwillnotbeusedtodeterminequalificationsasaproposedpublicschoolacademyboardmember.Thispagewillberemovedpriortoreviewoftheinformationcontainedintheapplication.

1.Name:

FirstMiddleInitialLast

2.MaidenNames/PreviouslyUsedNames:

3.Currentaddress(ifdifferentthaninthereappointmentapplication):

Position/JobTitle:

Anychangessinceyourlastapplication?YesNo

StreetAddressCityStateZip

4.Formeraddress:

StreetAddressCityStateZip

5.DateofBirth:

MonthDayYear

6.Gender:

Male

Female

7.Race:

White/Caucasian

Black/AfricanAmerican

Hispanic/Latino(a)

Asian/PacificIslander

AmericanIndian/AlaskanNative

Other(pleasespecify)

Application Verification

IrecognizethatallinformationsubmittedwiththisapplicationorgatheredbyLake SuperiorStateUniversityasaresultofthisapplicationbecomesamatterofpublicrecord,subjectbylawtodisclosureuponrequesttomembersofthegeneralpublic.IwillholdLake Superior StateUniversity,itstrustees,officers,employeesorauthorizedagentsharmlessfromliabilityforthedisclosureofanyinformationitreasonablybelievesistruebaseduponmyrepresentationsorresultingfromthisapplicationprocess.

Icertifythattheinformationprovidedinthisstatementis,tothebestofmyknowledge,trueandaccurate.

BysigningthisdocumentIacknowledgereceiptofthisdisclosureandauthorizeLake Superior StateUniversitytoobtainacopyofmycriminalrecordsreport.Iconsenttothereleaseofinformationconcerningmycriminalrecord,subjecttoanyrestrictionsthatIhaveincluded,toLake Superior StateUniversity,itsCharterSchoolsOfficeanditslegalcounsel.IspecificallyauthorizeLake SuperiorStateUniversitytoconductacriminalrecordscheckonmewiththeapplicablelocal,stateandfederallawenforcement agencies.

IwillholdLake SuperiorStateUniversity,itstrustees,officers,employeesorauthorizedagentsharmlessfromliabilityforthedisclosureofanyinformationitreasonablebelievesistruebaseduponmyrepresentationsorresultingfromthiscriminalrecordscheckconsentprocess.BymysignatureIassertandcertifythattheinformationprovidedis,tothebestofmyknowledge,trueandcomplete.

Signature

Date

Signature

Date