Consent To Perform Criminal History/background Check Form


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First Name ________________________ Middle Name ___________________ Last Name _______________________
Street address_____________________________ City____________________ State___________ Zip Code_______
Maiden name(s) or other name used in any other records____________________________________________________
*Date of Birth (MM/DD/YYYY)_____________________________________ *Gender__________________________
*Social Security Number______________________________________ *Race_________________________________
Driver’s License State of Issue______________________________ DL Number________________________________
*Required information, to be used for criminal history checks
I, ____________________________________, am an applicant for employment/volunteerism with Beaufort County Schools and
have been advised that as a part of the application process, the district conducts criminal history background checks. I do hereby
consent to the district use of any information provided during the application process in performing the criminal history checks. The
district has informed me that I have the right to review and challenge any negative information that would adversely impact a decision
to offer employment/volunteerism. In addition, I have been informed that I will have a reasonable opportunity to clear up any
mistaken information reported within a reasonable time frame established within the sole discretion of the district. Under the Fair
Credit Reporting Act, I have been advised that upon request I will be provided the name, address and telephone number of the
reporting agency as well as the nature, substance and source of all information.
The following are my responses to questions about my criminal history (if any).
ALERT: With the exception of minor traffic offenses or infractions, it is imperative that you list any and all convictions for any
offenses, including but not limited to: DWI, underage possession of alcohol, assault, worthless check, or any other offenses. It is
imperative that you list any offenses for which you have been convicted, plead guilty or no contest to, or received a prayer for
judgment, or received “deferred prosecution” which is not yet finalized or expunged.
Failure to disclose any of the above could result in denial of approval.
1. ____YES ____NO Have you ever been convicted or entered a plea guilty or nolo contendere (no contest) to any
criminal offense other than a minor violation (such as speeding). If yes, please provide details below.
State: _____________________ County: ______________________________ Date of Offense: ________________
Details of conviction: ____________________________________________________________________________
2. ____YES ____NO Have you ever received deferred adjudication/prosecution or similar disposition that was not
completed and resulted in a conviction for any federal, state or municipal offense (other than an offense for which all
records pertaining to the offense have been expunged)? If yes, please provide details below.
State:_____________________ County:________________________________ Date of Offense: _______________
Details of offense:_______________________________________________________________________________
Please be sure to complete page 2 of this form!
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