White Bear Lake School District Employee Criminal Background Check Form printable pdf download

CRIMINAL BACKGROUND CHECK ‐ MS 123B.03

COMBINED DISCLOSURE AND INFORMED CONSENT FORM FOR EMPLOYEES

(Important: Please read carefully before signing.)

White Bear Lake School District 624

District Center

4855 Bloom Avenue

White Bear Lake, MN 55110

651‐407‐7549

The Fair Credit Reporting Act requires that we inform you that a background investigation may be conducted as part of our

employee screening process. This may include an inquiry to obtain information regarding your employment history, police record,

education, qualifications, motor vehicle record, and/or credit and indebtedness. The primary objective of any investigation will be

to verify information you provided on your application or consent form for employment with this district (includes paid and

unpaid positions). A consumer report and/or an investigative consumer report may be obtained at any time during the

background process or during your time of employment with the district. Upon timely written request to our HR department, and

within 5 days of the request, the name, address and phone number of the reporting agency and the nature and scope of the

report (if one is made) will be provided to you. You have the right to request details of the report from the consumer reporting

agency.

Before any adverse action is taken, based in whole or in part on the information contained in the consumer report, you will be

provided a copy of the report, the name, address and telephone number of the reporting agency, a summary of your rights under

the Fair Credit Reporting Act, as well as additional information on your rights under the law.

The items of information requested below are required to process your background investigation. They are intended solely for

that purpose and will not be used in a discriminatory manner for the making of business decisions.

Are you willing to let us do a criminal background check on you? YES _____ NO _____

The following named individual has made application with this School District for employment as a

________________________________________________:

Full Legal Name of Applicant (please print):

_______________________________________________________

First

Middle

Last

Maiden, Previous or Alias:

______________________________________________________________________

Address: ___________________________________ City/State/Zip

_____________________________________

Date of Birth: ______________________________ Social Security Number: ________ ‐ ______ ‐ ________

Month/Day/Year

I hereby authorize White Bear Lake Area Schools ISD 624 and/or Trusted Employees Employment Screening and their agents,

without any reservation, to investigate my background as it pertains to criminal history pursuant to Minnesota Statute

123B.03 for the purpose of employment with the School District. I hereby release all persons, companies or other entities

furnishing such information from liability and responsibility in connection herewith.

This authorization shall be for a period of no longer than one year from the date of my signature.

________________________________________________

____________________________

Signature of Applicant

Date

White Bear Lake School District Employee Criminal Background Check Form

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