Release Of Information Form-Guilford County Schools
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1GUILFORD COUNTY SCHOOLS (GCS)
RELEASE OF INFORMATION FORM
The purpose of this form is to notify you, in accordance with present federal law that a background report, including a criminal records
check, will be obtained on you in consideration for employment and/or in the course of your employment with the Guilford County
Schools. I understand that the information below regarding sex, race and date of birth is requested for the sole purpose of gathering the
above information correctly, and will not be used to discriminate against me in violation of any law.
Last Name: ____________________________________________________
First: _____________________________________
Middle: _________________________________ Other (Maiden, Aliases, etc.):__________________________ Gender___________
Present Address: __________________________________________________
Social Security #: __ __ __ - __ __ - __ __ __ __
City: _________________________________________________ State: ______________
Zip Code: _____________________
Date of birth: _____ _____ _______ Home Phone: (
) _________________ Driver’s License #:________________State:________
Month
Day
Year
This information is voluntary and will not affect your opportunity for employment or terms or conditions of employment.
Ethnicity: Are you of Hispanic or Latino ethnicity-a person of Cuban, Mexican, Puerto Rican, South or Central American, or other
Spanish culture or origin regardless of race? ____Yes ____NO
Race: Please check one or more of the descriptions below corresponding to the racial group(s) with which you identify:
____American Indian or Alaska Native – A person having origins of North and South America (including Central America) and
maintain tribal affiliation or community attachment.
____Asian –A person having origins in any of the original peoples of the Far East, Southeast Asia or the Indian Subcontinent including,
for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
____Black or African American – A person having origins in any of the black racial groups of Africa.
____Native Hawaiian or Other Pacific Islander – A person having origins in any of the peoples of Hawaii, Guam, Samoa, or other
Pacific Islands.
____White – A person having origins in any of the original peoples of Europe, the Middle East or North Africa.
In consideration with this request, I authorize all corporations, former employers, credit agencies, education institutions, law enforcement
agencies, city, state, county and federal courts, and military services to release information about my background, including but not
limited to, information about my employment, education, consumer credit history, driving record, criminal record, and general public
record history, to the person or company with which this form has been filed, or its agents. This releases the aforesaid parties from any
liability and responsibility for collecting the above information. I understand I have the right to make a request of the Consumer
Reporting Agency, upon proper identification and the payment of any authorized fees, the information in its files on me at the time of my
request. I further authorize ongoing procurement of the above-mentioned reports at any time during my employment (or contract).
Please list all cities, counties and states in which you have lived within the past 20 years. Attach another page if necessary:
___________________________________________________________________________________
________
______________
Street
City
County
State
Dates
___________________________________________________________________________________
________
______________
Street
City
County
State
Dates
___________________________________________________________________________________
________
______________
Street
City
County
State
Dates
___________________________________________________________________________________
________
______________
Street
City
County
State
Dates
Please list any felony or misdemeanor criminal convictions, guilty pleas, pleas of no contest, deferred prosecutions, prayers for
judgment, and pending charges. Your listing should include DWI/DUI convictions, guilty pleas etc. but exclude minor traffic
violations. Please provide date(s), court of jurisdiction, and state.
______________________________________________________________________________________________________________
__________________________________________________________________________________________
Are you a retiree of the NC Teachers and State Employees Retirement System? ____ yes ____ no
If yes, when did you retire? ______________ (mm/dd/yyyy) If yes, have you served a six month break in service? ___ yes ___ no
Position nominated for: __________________________________________ Previously worked for GCS: _____ yes ____ no
School/Location:_______________________________Applicant’sSignature:_____________________________Date:____________
Guilford County Schools-Staffing Office Fax #: (336) 370-8062
Revised 04/07/10
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