404-5f - Background Check Form printable pdf download

404-5f - Background Check Form

Letterhead

Background Check

Date:___________________

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

provision of athletic coaching services or other extracurricular academic coaching services.

Full Name of Individual:__________________________________________________________

(please print)

Last

First

Middle

Maiden, Previous, Alias:__________________________________________________________

Date of Birth:_________________________

Sex (M or F): ________

Month/Day/Year

I authorize the Minnesota Bureau of Criminal Apprehension to disclose all criminal history record

information to ____________________________________________________________

pursuant to Minn. Stat. § 123B.03 for the purpose of ___________________________________

_________________________________________ with this School District.

CONDITIONAL HIRING: I understand that the School District may permit me to commence my

employment duties or provide athletic coaching services or other extracurricular academic

coaching services pending completion of the criminal history background check and acknowledge

and agree that my employment or services may be terminated based on the result of the

background check.

The expiration of this authorization shall be for a period no longer than one year from the date

of my signature.

__________________________________________

__________________

Signature of Applicant or Potential Service Provider

Date

The School District should forward this executed form, along with a check or money order in the

amount of $15.00 payable to the “MN BCA” and a self-addressed, stamped envelope, to:

Minnesota Bureau of Criminal Apprehension

Criminal Justice Information Section

Attn: Record Checks

1430 Maryland Avenue E, St. Paul, MN 55106

404-5F

404-5f - Background Check Form