Exhibit_C-_VCPP_Criminal_Background_Check_Form.pdf

Revised 05/22/2025 PLEASE SUBMIT SINGLE SIDED IN ORIGINAL FORMAT

DEPARTMENT OF PUBLIC PROTECTION CRIMINAL RECORDS CHECK

SOCIAL SECURITY NUMBER COLLECTION DISCLOSURE

This statement is being provided to you pursuant to Section 119.071(5)(a), Florida Statutes.

The County of Volusia collects your social security number and may disclose your social security number to a commercial entity for the following purposes, including but not limited to: background investigations, criminal record and/or driving history checks, drug testing administration, employee or volunteer application and payroll processing, tax reporting, and (or any purpose allowed under law not limited by protection under state or federal privacy laws.

Social security numbers are also used as a unique numeric identifier and may be used for search purposes. The County of Volusia may disclose social security numbers to another agency or governmental entity if it is necessary for the receiving agency or governmental agency to perform its duties and responsibilities.

PLEASE CONDUCT A RECORDS CHECK TO INCLUDE: F.C.I.C., N.C.I.C., C.J.I.S., Criminal History, and Driver's License on the listed application. Your cooperation is appreciated.

(EXAMPLE: Corrections, Fire Services, Aramark, Vital Core, Animal Control, Medical Examiner, Volunteer & Temporary Services, etc.)

ORGANIZATION:

NAME:

OTHER LEGAL/MAIDEN:

HOME ADDRESS:

EMAIL ADDRESS:

TELEPHONE #:

PLACE OF BIRTH:

DATE OF BIRTH:

SOCIAL SECURITY #:

DRIVERS LICENSE / STATE:

HEIGHT:

WEIGHT:

EYE COLOR:

HAIR COLOR:

GENDER:

RACE: _____________________________________________________

APPLICANT SIGNATURE DATE

AUTHORIZED BY: ________________________________________________ ________________

DIVISION REPRESENTATIVE DATE

APPLICATION SUPPLEMENT

Note: For explanation, attach separate sheets of paper as necessary

Yes / No

Yes / No

Yes / No

1. Have you ever had a legal name change?

If yes, please provide court documentation.

2. Have you ever been arrested, received a notice to appear, charged, convicted, pled nolo contendere or pled guilty to any criminal violation, regardless if the record was sealed or expunged?

If yes, explain each situation.

3. Have you ever had any disciplinary action, been involuntarily terminated from employment, or been asked to resign? If yes, please explain.

4. Have you ever been the subject of an Internal Affair or similar investigation for policy/procedure or misconduct issues? If yes, please explain.

5. Have you used, sold or ever been charged with possession of any illegal narcotics and/or substances in the past? If yes, please explain. How often? When was your last use?

6. Have you ever had any certificate, driver’s license or professional license revoked or suspended under any state, federal or other law? If yes, please explain where, when and why.

7. Do you or have you ever resided with an individual that has been convicted of a felony?

If yes, please explain.

8. Do you currently have a Social Media account such as Facebook, Instagram, Twitter, etc?

If yes, please provide accounts

Yes / No

Yes / No

Yes/ No

Yes / No

Yes / No

AFFIDAVIT

I swear or affirm that I am a citizen of the United States, by birth or naturalization, that I have never been convicted of a felony or a 1st degree misdemeanor, that I have a valid high school diploma or its equivalent, that my discharge (if any) from the Armed Forces was under honorable conditions, that I am of good moral character, that I have read all of the information contained in this affidavit and my employment application are correct, and that all other information I will furnish in conjunction with my application is true and correct. If it is determined at any time that any information is not true, employment with Volusia County may be terminated immediately.

(Signature of Applicant)

*For purposes of this application, a finding of guilt or a plea of guilty or no contest (nolo contendere) after October 1, 1980, is the equivalent of a conviction, even if sentence is suspended or adjudication of guilt withheld.

Subscribed and sworn to before me this _____ day of ________, 20___ _______________________________________ at _____________________ Florida. Notary Public

PERSONAL INQUIRY WAIVER

Authority for Release of Information

Concerned Person or Authorized Representative of Any Organization, Institution or Repository of Records:

APPLICANT'S NAME: ______________________________________________________________

DATE OF BIRTH: _____________________________ SOCIAL SECURITY NO.: ________________________

I respectfully request and authorize you to furnish the Volusia County Division of Corrections any and all information that you may have concerning any criminal history information or information related to any activity in which I have been associated with any Law Enforcement Agency.

Information not limited and to include any arrest, notice to appear, charged convicted, pled nolo contendere, or pled guilty to any criminal violation, regardless if the record was sealed or expunged.

I hereby release you, your organization or others from any liability or damage, which may result from furnishing the information, requested above. I hereby agree and promise to indemnify and save harmless the addressee, its officers, agents, servants or employees from and against any and all liability, claims, demands, damages, expenses, fees, fines, penalties, suits, proceedings, actions, and cost of actions including attorney fees, of any kind and the nature arising or growing out of or in any way connected with the disclosure of the requested information.

I have read and understand the above.

Date Signature of Applicant

State of Florida County of Volusia

Before me personally appeared, ________________________________ who says that he/she executed the above instrument of his/her own free will and accord, with full knowledge of the purpose, therefore.

Sworn and subscribed in my presence this ________ day of __________, 20______.

My commission expires on __________, 20____. _______________________ Notary Public

Personally Known____-OR- Produced Identification_____

Type of Identification Produced: _____________