Attachment F - Contractor Back ground Check Consent Form_.pdf

CPP 3.6 Attachment 2 Rev. 2015

Authorization to Conduct Criminal Records Check, Driving History Records Check, and Credit Reports Check (Please Read Carefully Before Completing and Signing)

The items of personal information requested below are needed to process your background investigation. This information is intended solely for that purpose and shall not be used in a discriminatory manner by the parties noted below in the making of appropriate business decisions.

Printed full name of applicant and current address:

Name (First, Middle, Last)

Address Line 1

Address Line 2 City, State, Zip

Social Security Number Date of Birth (m/d/y) / /

Driver’s License Number Race

State Issued Gender

Have you ever been convicted of a crime (Omit minor traffic offenses)? Yes No

If Yes, please explain charges and disposition. (Use an additional sheet of paper if necessary)

What State, What County, and What Year did these convictions occur?

Have you ever engaged in sexual abuse in a prison, jail, lockup, community confinement facility, juvenile facility or other institution (as defined in 42 U.S.C. §1997)? Yes No

Have you been convicted of engaging or attempting to engage in sexual activity in the community facilitated by force, overt or implied threats of force or coercion or if the victim did not consent or was unable to consent or refuse? Yes No

Have you been civilly or administratively adjudicated to have engaged in the activity described in the previous question? Yes No

Have you been involved in any incidents of sexual harassment? Yes No Date: Location:

Findings:

I authorize the Kentucky Department of Corrections and their agents to investigate my background as part of my application for employment, promotion or as a contractor or volunteer.

This may include information contained in public records, which may include credit history, criminal files at the county, state and federal jurisdiction levels, and motor vehicle records.

Moreover, I hereby release the State of Kentucky and the Kentucky Department of Corrections and any agent acting on its behalf from any liability of whatsoever nature of requesting information from any person.

Signature of Applicant Date / /