Background Check Form Hr Page 3

Rev. 03 April 2013

UT Health Northeast

CRIMINAL BACKGROUND CHECK FORM

Human Resources

NON-EMPLOYEE BACKGROUND REPORT

THIS SECTION TO BE COMPLETED BY HUMAN RESOURCES

Name of Applicant:

Date of Birth:

Job Title of Position:

Department Name:

Authorized Signature for HR:

Expected Date of Hire: _______________________Deliver ID Badge to HR by: _________________

THIS SECTION TO BE COMPLETED BY UTHSCT POLICE DEPARTMENT

________ Applicant background is clear.

________ Conviction data offense(s) do not bar hiring for employment as it relates to the job.

________ Conviction data offense(s) bar hiring for employment as it relates to the job.

________ Applicant falsified the questionnaire which constitutes grounds for refusing employment.

Robert Cromley, Chief of Police

Date

Return completed form to Human Resources/Employment Services

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Parent category: Legal