Authorization Release Form For Obtaining Pa Criminal History Check printable pdf download

AUTHORIZATION & RELEASE FORM FOR OBTAINING

PENNSYLVANIA STATE POLICE/FBI CRIMINAL HISTORY BACKGROUND

I, ______________________________________________, have been advised and

understand that, as a condition of my employment with UPMC Horizon Transitional Care

Center, criminal history background clearances must be obtained from the Pennsylvania

State Police or the Federal Bureau or Investigation (FBI). I understand that Act 169 of

2996, the Older Adults Protective Services Act, prohibits the employment of persons

convicted of certain crimes and that this information is being obtained in compliance with

this Act.

Effective July 1, 1998, UPMC Horizon and its affiliates are required by Pennsylvania Law

to require applicants for employment, including some contract employment and certain

existing employees to submit for processing a Pennsylvania State Police/FBI criminal

history background check in accordance with the Older Adult Protective Services Act.

I hereby affirm that I have not been convicted of one of the offenses designated in the Older

Adult Protective Services Act, 169 of 1996, as amended by Act 13 of 1997, as listed in the

attachment to this authorization and release form.

I understand that if I have not resided in the Commonwealth of Pennsylvania for two years

prior to application of employment, I must submit a full set of fingerprints to the

Pennsylvania State Police for forwarding to the Federal Bureau of Investigation for a

national criminal history check.

I have ___ have not ___ been a resident of Pennsylvania for two (2) uninterrupted years or

more prior to the date of signing this form. (check one)

I understand that applicants who have been made an offer of employment and accept that

offer may be employed on a provisional basis for 30 days pending return of the State

Police report and may be employed on a provisional basis for 90 days if an FBI report is

necessary.

I agree to cease employment with UPMC Horizon or its affiliate immediately in the event

the Pennsylvania State Police or FBI Criminal History Background Report indicates I have

been convicted of one of the prohibitive offenses. Additionally, I agree to cease

employment [Option: to be placed on layoff] with UPMC Horizon if the requested

Pennsylvania State Police report is not received by UPMC Horizon by the 30

day of the

provisional hire, or if the FBI report is not received by the 90

day of the provisional hire.

Signature of Applicant/Provisional Employee/Current Employee

Date

Authorization Release Form For Obtaining Pa Criminal History Check