Background Investigation and Release of Information Authorization – Human Resources

Background Investigation & Release of Information Authorization Form

"*" indicates required fields

Disclosure

Required Disclosure *

Please read carefully before submitting.

The Fair Credit Reporting Act requires that we inform you that a background investigation may be conducted as a part of our employment screening and selection process. Kalamazoo College may obtain for employment purposes a consumer report (also referred to as a “credit report”) or an investigative consumer report concerning applicants or employees. This may include an inquiry to obtain information regarding your character, general reputation, personal characteristics and mode of living. Upon your written request within a reasonable period of time, additional information as to the nature and scope of the report, if one is made, will be provided, along with a written summary of your rights as a consumer. In addition, if a report is made, you have the right to request details of the report from the consumer reporting agency.

We ask that you authorize Kalamazoo College to obtain such a report, and that you consent to the report being furnished to Kalamazoo College. To do so, please sign the authorization statement on this page below. The items of information requested below are needed to process your background investigation. They are intended solely for that purpose and will not be used in a discriminatory manner for the making of business decisions.

I understand.

Reason for Submission and Associated Unit

Indicate the reason for submission *

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. *

Legal Information

Legal Name *

First Middle Last Suffix

Address *

Street Address Address Line 2 City State ZIP Code

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. *

COVID Vaccination Record

All faculty and staff are required to be vaccinated against COVID-19 before your first day of work. Please provide proof of your COVID vaccination record below. If you do not have your record you can submit it at a later time through the Vaccination Recording form.

Have you received at least one vaccination injection for COVID-19? *

Pfizer and Moderna require two injections. Johnson & Johnson requires one injection.

Yes

Upload a file containing proof of vaccination. *

Be sure that the name and date(s) of injection are clearly visible. Email Renee at renee.boelcke@kzoo.edu if technical issues arise.

Max. file size: 3 MB.

Since you are unable to provide the required vaccination record at this time you will need to submit your proof through the Vaccination Reporting form before your first day of work.

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