Background Check Form - Broward County Public Schools (Page 2 of 4) in pdf

PLEASE CIRCLE ONE

Yes

10. Have you ever been placed on probation in a criminal proceeding?

Yes

11. Have you ever paid a fine in a criminal proceeding?

Yes

12. Have you ever failed to appear in court or forfeited bond in a criminal proceeding?

Yes

13. Have you ever had criminal charges pending against that were later dropped, abandoned,

dismissed or nolle prosequi ?

Yes

13. Are you currently on probation or parole?

If you answered “Yes” to any of the previous questions (1-13), you must fully explain below and/or use an

additional sheet of paper, if necessary.

EXAMPLES OF CRIMINAL OFFENSES: Assault, battery, disorderly conduct, domestic violence, DUI/DWI, fraud (welfare/food stamps) loitering,

prostitution/solicitation, robbery, shoplifting, theft (grand/ petty), trespassing, worthless checks. NOTE: This is not a complete list and is intended to

provide examples only.

You must list all convictions including juvenile incidents and those in which adjudication was withheld and/or records were

sealed/expunged.

PLEASE CIRCLE ONE

Yes

14. Have you ever had a teaching certificate revoked or suspended? If yes, in what state and

when?

Yes

15. Have you ever had sanctions placed on your teaching certificate for any reason?

Yes

16. Have you ever been denied a teaching certificate anywhere?

Yes

17. Is disciplinary action currently pending anywhere against your teaching certificate?

Yes

18. Are you currently under investigation by any local, state or federal agency or entity for any

wrong doing, either criminal, civil or administrative?

Yes

19. Have you ever been dismissed or asked to resign from employment? (Please explain below.)

If you answered “Yes” to any question above, you must fully explain below. Additionally, you must provide the

police report/incident report and the court’s final disposition (including your plea and sentencing) for each

incident. If the documents are no longer available, the respective agency and/or court must provide you a

statement on their letterhead that indicates the documents are no longer available. **Note – your file will not be

processed until all documents are received.

INCIDENT #1 (Request 2nd sheet if more than one incident)

If Arrested, Where?:

Date of Arrest:

Arresting Agency:

Offense:

Please provide detailed explanation:

Final Disposition:

By signing this document, I certify that I have carefully read and fully understand each question and that all information

contained herein is true and accurate. My signature further certifies that there is no falsification of any information,

omission of any information requested or any misrepresentation of information requested. I also understand that my

fingerprints will be submitted to the Florida Department of Law Enforcement and the Federal Bureau of Investigation for a

complete fingerprint based criminal history check.

By my signature, I authorize the Broward County School Board to conduct any investigation necessary to verify all

information identified on this form. My signature on this document provides for the release of any sealed or expunged

records in my name by any court. Included in this grant of authority is my permission to contact any and all former

employers and other persons acquainted with me or in possession of information concerning me to supply such

information to the Security Clearance Office. All monies received as part of the fingerprinting process are non-

refundable.

By my signature, I certify that I know, understand, and agree that any false statement or omission of information

requested 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.

Signature of Applicant

Date

OFFICE USE ONLY:

Job Location:

Job Title:

Rev. 3/97; 8/97; 10/97; 2/98; 1/00; 7/02; 3/04; 11/04; 5/05; 11/06; 01/14

Form #4720

Background Check Form - Broward County Public Schools Page 2

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