Consent To Perform Criminal History/background Check Form (Page 2 of 2) in pdf

3. ____YES ____NO Have you ever been convicted of any criminal offense in a country outside the jurisdiction of the

United States? If yes, please provide details below.

Country:_________________________ City:_________________________ Date of Offense:___________________

Details of conviction:_____________________________________________________________________________

______________________________________________________________________________________________

4. ____YES ____NO As of the date of this consent form, do you have any pending criminal charges against you OR are

you in a deferred prosecution or drug diversion program? If yes, please provide details below.

State:______________________ County: ___________________________ Date of Criminal Charge: ____________

Details of pending charges:________________________________________________________________________

______________________________________________________________________________________________

This section is to be used to list all counties and states of residence since high school graduation or age 18.

City/Town

County

State

__________________________________________________________________________________________________

I hereby certify that all information provided in this consent form is true, correct and complete. If any information proves to

be incorrect or incomplete, I understand that grounds for cancelling of any and all offers of employment/volunteerism will exit

and I will be dismissed, if hired, at the discretion of the district. Furthermore, I authorize the Beaufort County Board of

Education to make an investigation of my personal employment history; to conduct a criminal records check, which may

include confirmation by fingerprint identification; and my previous employer(s) to provide all information which they may

have regarding my past employment. I release the Beaufort County Board of Education and all previous employer(s) of any

potential liability resulting from the release of information and of any potential liability. I understand that a consumer report

or an investigative consumer report (hereinafter referred to as “Report”) may be procured at any time during my candidacy

for employment and/or during my employment, contract or volunteer work.

I understand the Report may include

information as to my character, work habits, performance, and experience, along with reasons for termination of past

employment. I understand that as directed by Company policy, information may be obtained from public and private sources

and may include information related to: social security number verification, criminal records, credit history, driver/motor

vehicle records, employment, education, credentials and personal references. I also understand that the information I provide

regarding my sex, race and date of birth will be used for the sole purpose of gathering the above mentioned information

correctly, and will not be used to discriminate against me in violation of any law.

Signed this _______________________ day of____________________, 20_______

Applicant (Print Name) _________________________________________________

Applicant’s Signature___________________________________________________ Date:________________________

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Consent To Perform Criminal History/background Check Form Page 2