Consent For Criminal Background History Check
ADVERTISEMENT
1Consent for Criminal Background History Check
PERSONAL INFORMATION:
Print Name: ____________________________________________________________________________________
(First)
(Middle)
(Last)
Maiden Name/Alias: __________________________ Social Security Number: ____________________________
Driver’s License Number /State: _________________
Gender: □ Male □ Female
Date of Birth: _________
Phone#: _____________ Email Address: __________________________________________________________
ADDRESS HISTORY:
Current: _____________________________
___________________ ____ __________
______
Street
City
State
Zip
# of Years
Previous: _____________________________
___________________ ____ __________
______
Street
City
State
Zip
# of Years
Previous: _____________________________
___________________ ____ __________
______
Street
City
State
Zip
# of Years
I hereby give my permission to the Autism Academy of SC to obtain information relating to my criminal history record.
The criminal history record, as received from the reporting agencies, may include arrest and conviction data as well as
plea bargains and deferred adjudications and delinquent conduct committed as a juvenile. I understand that this
information will be used, in part, to determine my eligibility for an employment/volunteer position with this organization. I
also understand that as long as I remain an employee or volunteer here, the criminal history records check may be
repeated at any time. I understand that I will have an opportunity to review the criminal history as received by the Autism
Academy of SC, and a procedure is available for clarification if I dispute the record as received. I also understand that
the criminal history could contain information presumed to be expunged.
I hereby affirm that my answers to the foregoing questions are true and correct and that I have not knowingly withheld
any fact or circumstances that would, if disclosed, affect my application unfavorably. I understand that any false
information submitted in this application may result in my discharge. I, the undersigned, do, for myself, my heirs,
executors and administrators, hereby remise, release and forever discharge and agree to indemnify the Autism Academy
of SC and each of their officers, directors, employees and agents and hold them harmless from and against any and all
causes of actions, suits, liabilities, costs, debts and sums of money, claims and demands whatsoever (including claims
for negligence, gross negligence, and/or strict liability of the Autism Academy of SC) and any and all related attorneys’
fees, court costs and other expenses resulting from the investigation of my background in connection with my application
to become a volunteer/staff member.
Signature: ___________________________
Date: _________________
_ _ _ _ _ _ _
_ __ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ __ _ _ _ _
_
OFFICE USE ONLY
□
□
□
Purpose of check:
Staff employment/internship
Volunteer
RBT Trainee
Background check search completed by: ____________________________________________on _________________________
□
□
□
_______
Fee: $ _________
Payment Method (Volunteers):
Check #_____
Cash
other: _____
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal