Background Check Form Hr (Page 2 of 3) in pdf

Background Check Form Hr Page 2

Rev. 03 April 2013

UT Health Northeast

CRIMINAL BACKGROUND CHECK FORM

Human Resources

I hereby authorize UT Health Northeast to obtain and/or its agent to obtain and furnish information to UT Health Northeast

related to my criminal background. I consent to providing my fingerprints if required in connection with the criminal background

check. I hereby release UT Health Northeast and all its agents and employees, the law enforcement agency, and all

employees of law enforcement agencies furnishing information from all liability resulting from the furnishing of this information

to UT Health Northeast. I certify that the statements made by me on this form and in connection with my application whether on

this form or not, are true, complete and correct to the best of my knowledge and belief and I understand that any misstatement,

falsification, or omission of information shall void my application and be grounds for refusal to hire or, if hired, termination. I

certify that I will report in writing any charges or conviction, excluding misdemeanor offenses punishable only by fine, occurring

after the date of this application to UT Health Northeast Office of Human Resources. If circumstances require that an offer be

made before the completion of an investigation, the offer is contingent on the completion of a satisfactory criminal background

investigation. I understand that any false statements made herein will void my Application for Employment and any actions

based on it.

Applicant/Employee Signature

Date

THIS SECTION TO BE COMPLETE BY THE EMPLOYING DEPARTMENT

Applicant/Employee status:

Faculty ______

Staff ______

Student ______

Posting Number:

Posted Job Title:

Department Name:

Department Phone Number: (ext) ____________

Department Contact:

Signature:

Date: ______________

Send this completed form to UT Health Northeast, Human Resources [Fax 903-877-7729)

Page 2 of 3

Background Check Form Hr Page 2