Background Check Form

Background Check Form

AUTHORIZATION FOR RELEASE OF INFORMATION

 

I understand that it will be necessary for USD 435 to investigate my background, including any possible criminal background.  Therefore, I hereby give my consent for any agency to release this information requested by USD 435.  In addition, I request and authorize any law enforcement agency, including the Kansas Bureau of Investigation, to furnish USD 435 with all criminal history record information as defined in KSA 1985 Supp, 22-4701 (b).  I understand that the persons and agencies to be contacted may include  employers (both current and former), courts (juvenile and adult), police and other law enforcement bodies, social service, and any other persons or agencies with whom I have had contact.  

 

By this release, I voluntarily waive all right of recourse and release USD 435 of Abilene, Kansas, from all liability related to compliance with this authorization.

 

A criminal history check of the Kansas central records repository is requested for the following individual.

 

A fingerprint card is not included.

 

FULL NAME:      

      

ANY OTHER NAME USED:  

                     (Alias / Maiden Name)

 

CURRENT ADDRESS:  

            Street         City      State / Zip

 

GENDER:    BIRTHDATE:    SS#  

 

PLACE OF BIRTH:  

 

ADDITIONAL INFORMATION:  

 

 

 

 

 

SIGNATURE:     DATE:  



Security Measure
Website by SchoolMessenger Presence. © 2017 West Corporation. All rights reserved.