Background/Driving Record Investigation and Release of Information Authorization – Human Resources

"*" indicates required fields

Disclosure

Reason for Submission and Associated Unit

Indicate the reason for submission *

K Students: Select options 2 or 3 only.

I have applied for employment or to be a volunteer

I am requesting authorization to drive a College vehicle for College-related purposes

Other

Name of the unit in which you will be working, volunteering, or otherwise associated. *

Transportation Policy

Legal Information

Legal Name *

First Middle Last Suffix

Address *

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email *

Primary Phone *

Date of birth *

Gender *

Female

Male

Other

Social Security Number *

Driver's License Number

Driver's License State of Issuance

Driver's License Expiration Date

Indicate 01/01/1900 if there is no expiration date.

Other name(s) used

Criminal History

Are there any felony charges pending against you? *

Yes

Please indicate the crime(s), country, state, county, and year. *

Have you ever been convicted of a crime? *

Yes

Please indicate the crime(s), country, state, county, and year. *

Final Authorization and Signature

Authorization and consent for release of information *

After reading this document, I fully understand the contents and authorize Kalamazoo College to conduct a background verification. I authorize Kalamazoo College and its agents to request and receive an investigative consumer report concerning me and to investigate my background as it pertains to employment considerations. This may include investigation of employment history and performance, personal/professional references, educational history, licenses and information contained in public records including credit, criminal, driving record, motor vehicle data and worker’s compensation. I release all persons, companies, or corporations furnishing such information from liability and responsibility.

I understand and agree that: The information supplied was submitted by myself, and all information is true and correct, to the best of my knowledge. I understand that false or misleading information given in my application and/or interview(s) will be considered as cause for possible dismissal and/or discharge. I also understand that I am to abide by all rules and regulations of the company.

The company has my authorization to thoroughly investigate my work and personal history. I understand that the information supplied by me, regarding my: Employment History, Education (including an authorization to release transcripts), Credit History, Criminal History, Medical and Professional Licensing, Motor Vehicle Record(s), Residence History, and References, will be utilized as part of the processing procedure. A background check will be conducted to verify the veracity of the information submitted and will be utilized to develop information concerning my character, general reputation, personal characteristics, and mode of living. I will hold no person liable for giving or receiving information in this investigation. I hereby authorize that:

TR Information Services, an agent of Kalamazoo College, may be asked to make a thorough check of my credit history, driving history, criminal history, past employment, education, and activities. A copy of this form is as valid as the original.

I authorize and consent.

Signature

Summary of your rights under the Fair Credit Reporting Act