Agency Background Check Form
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Agency Background Check Form
University of California, Riverside
Applicant Information
(Please type or print legibly)
Name:________________________________________________________________________
first
middle
last
Indicate Other Alternative Names: _________________________________________________
Address:______________________________________________________________________
City:__________________________________________ State:________ Zip:_______________
Social Security Number: ____________________________
Driver's License Number:____________________________
State Driver's License Issued (if not CA):_______________
Date of Birth:______________________________________
Required Services
Additional Services
(the department may request these additional
services and may ask for documents supplying the
- County Criminal Check
required information.)
Please list applicable counties
(worked/resided)
Driving Record
-
________________________________
-
Employment Verification
________________________________
-
Education Verification
________________________________
-
Consumer Credit Report
- Social Security Number Trace
-
Military History
(Note to personnel: please mark "1" on this
category when making the request)
Privacy Notification
The State of California Information Practices Act of 1977 (effective July 1, 1978) requires the University to provide the following
information to individuals who are asked to supply information about themselves.
rmation on this form is for conducting job-related background checks on persons filling "critical"
The principal purpose for requesting the info
positions with responsibility for security of property or people; access to cash, checks, disbursements or receipts;
authority for
committing
financial resources; and/or access to financial and payroll/ personnel systems.
Furnishing all information on this form is mandatory. Failure to provide the information may delay or prevent completion of the action for
which the form is being filled out. Information furnished on this form may be used by various University departments for personnel
administration and will be transmitted to the federal and state governments as required by law. Individuals have the right to review their
own records. The department is responsible for maintaining the information supplied on the Agency Background Check Request Form.
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Parent category: Business