Attachment F - Contractor Back ground Check Consent Form_.pdf
PDF 377 KB Posted
- Attached to
- RFP-102-26 CM/GC DOC EKCC Facade & HVAC
- Solicitation number
- RFP 785 2600000119 1
- Issued by
- Metcalfe County, Kentucky
About this file
This is a Contractor Background Check Consent Form from the Kentucky Department of Corrections, used as part of the application process for employment, promotion, contractor positions, or volunteer roles. The form authorizes the Kentucky Department of Corrections and its agents to conduct comprehensive background investigations on applicants, including criminal records checks, driving history records checks, and credit reports checks. Applicants must provide personal information including full name, current address, Social Security number, date of birth, driver's license number, race, and gender. The form requires disclosure of any criminal convictions (excluding minor traffic offenses), with details on charges, disposition, state, county, and year of conviction. Additionally, applicants must disclose any history of sexual abuse in institutional settings, sexual activity facilitation through force or coercion, civil or administrative adjudication for sexual activity, and involvement in sexual harassment incidents.
By signing the consent form, applicants authorize the Kentucky Department of Corrections to access public records, credit history, criminal files at county, state, and federal jurisdiction levels, and motor vehicle records as part of the background investigation process. The form explicitly releases the State of Kentucky and the Kentucky Department of Corrections from any liability associated with requesting information from any source during the investigation. This background check authorization is a standard prerequisite requirement for contractor eligibility and must be completed, signed, and dated by the applicant before proceeding with the application process.
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Text version
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 / /
File details come from the government source that posted it. Updated .