Background Check Form - Broward County Public Schools printable pdf download

SECURITY CLEARANCE USE ONLY: Local Check:

Comp. No.

MO#/CC Type

Payment amount

Order #

The School Board of Broward County, Florida

BACKGROUND SCREENING

IMPORTANT – READ BEFORE COMPLETING THIS FORM

The School Board of Broward County will receive information on all records, including juvenile, that have been sealed,

expunged, or where adjudication was withheld. To omit a response or to be untruthful in your response, regardless

of any previous information received from an attorney, a judge, or any third party will be considered falsification

and is a cause for dismissal from employment, consideration for employment, denial of clearance to enter onto

school grounds and/or participate in the activity for which this background screening is being conducted.

THIS FORM MUST BE TURNED IN PRIOR TO BEING FINGERPRINTED

SS#

AME

Last

First

Middle Initial

Maiden

DDRESS

HONE

Street

APT#

City

State

Zip

EMAIL ADDRESS:

CELL:

IMPORTANT NOTE

The intended use of the above email address is to communicate solely with the applicant regarding the background screening.

FINGERPRINTING INFORMATION

BIRTHDATE :_________________

STATE, COUNTRY OF BIRTH: ___________________

GENDER:

Male

Female

RACE: (Select one only)

American Indian or Alaskan Native

Asian

Black or African American

White

Native Hawaiian or Other Pacific Islander

ETHNICITY: (Select one only)

Hispanic/Latino

Not Hispanic/Latino

HAIR:

Black

Blonde

Brown

Gray

Red

Bald

EYES:

Blue

Brown

Green

Hazel

Black

Gray

HEIGHT:________ WEIGHT: _______

At the time of your background screening, fingerprints will be researched by local, state and federal law enforcement agencies. Sealed

or expunged records must be revealed to the School Board of Broward County pursuant to F.S. 943.0585. Your employment with the

Broward County School District is temporary and probationary pending successful processing of your background. The following

questions must be answered truthfully. A "Yes" answer to any of the following questions does not automatically deem you ineligible.

However, to omit a response or to be untruthful in your response, regardless of any previous information received from an

attorney, a judge, or any third party will be considered falsification and is a cause for dismissal from employment,

consideration for employment, denial of clearance to enter onto school grounds and/or participate in the activity for which

this background screening is being conducted.

PLEASE CIRCLE ONE

Yes

1. Have you ever been convicted of an offense (misdemeanor or felony) other than a minor

traffic violation? (Driving under the Influence [DUI] and Driving while Intoxicated [DWI]

convictions are not minor and must be reported.)

“Convicted” has the same meaning as in Florida Statute 943.0435. Specifically, “convicted” means there has been a determination of guilt as a result of

a trial or the entry of a plea of guilty or nolo contendere, regardless of whether adjudication is withheld, and includes an adjudication of delinquency of a

juvenile as specified in this section. Conviction of a similar offense includes, but is not limited to, a conviction by a federal or military tribunal, including

courts-martial conducted by the Armed Forces of the United States, and includes a conviction or entry of a plea of guilty or nolo contendere resulting in a

sanction in any state of the United States or other jurisdiction. A sanction includes, but is not limited to, a fine, probation, community control, parole,

conditional release, control release, or incarceration in a state prison, federal prison, private correctional facility, or local detention facility.

Yes

2. Have you ever been found guilty of a criminal offense?

Yes

3. Have you ever entered a nolo contendre or no contest plea in a criminal proceeding?

Yes

4. Have you ever had a criminal record sealed?

Yes

5. Have you ever had a criminal record expunged?

Yes

6. Have you ever participated in any type of pre-trial intervention/diversion program, including

but not limited to community service or probation that resulted in the charges being