Criminal History | SBC Forensics

Gateway Home Page

Athena Request

CRIMINAL HISTORY BACKGROUND CONSENT

FIRST NAME

MIDDLE NAME

LAST NAME

ALL FORMER/MAIDEN NAMES (IF APPLICABLE)

DRIVER'S LICENSE NUMBER

The 8-character ID number located on your ID

STATE ISSUED:

CURRENT ADDRESS

CITY

STATE

ZIP CODE

COUNTY

DATE OF BIRTH

MM/DD/YYYY

SOCIAL SECURITY NUMBER

OHIO RN LICENSURE NUMBER

OHIO RN LICENSURE EXPIRATION DATE

OHIO APRN LICENSURE NUMBER

Please type N/A if not applicable

OHIO APRN LICENSURE EXPIRATION DATE

Please type N/A if not applicable

Have you ever had any board actions, sanctions, or limitations taken against your license in any state? (Explanation if YES must be provided below)

YES, EXPLANATION BELOW

IF YES, PLEASE EXPLAIN:

Have you ever been convicted or plead guilty before a court of any federal, state, or municipal criminal offense? (Excluding minor traffic violations) (Explanation if YES must be provided below)

YES, EXPLANATION BELOW

IF YES, PLEASE EXPLAIN:

Have you ever received deferred adjudication or similar disposition for any federal, state, or municipal criminal offense? (Explanation if YES must be provided below)

YES, EXPLANATION BELOW

IF YES, PLEASE EXPLAIN:

Have you ever received probation or community supervision for any federal, state, or municipal criminal offense? (Explanation if YES must be provided below)

YES, EXPLANATION BELOW

IF YES, PLEASE EXPLAIN:

Have you ever been convicted of any criminal offense in a country outside the jurisdiction of the United States? (Explanation if YES must be provided below)

YES, EXPLANATION BELOW

IF YES, PLEASE EXPLAIN:

As of the date of this authorization, do you have any pending criminal charges against you? (Explanation if YES must be provided below)

YES, EXPLANATION BELOW

IF YES, PLEASE EXPLAIN:

Has your license been revoked, suspended, or given limited privileges within the last 5 years? (Explanation if YES must be provided below)

YES, EXPLANATION BELOW

IF YES, PLEASE EXPLAIN:

Please list the previous addresses you have lived at within the last 10 years:

This authorization and consent for release of personal information acknowledges that:

SBC Forensics, LLC. (Hereafter referred to as "Company") and/or its agent, may now, or at any time I am assigned to, volunteer with or am employed by this Company, conduct investigations whether the records are of a public, private or confidential nature. These investigations might include, but are not limited to, searches of educational institutions attended; financial or credit institutions, including records of loans; records of commercial or retail credit agencies; other financial statements; records of previous employment, including work history, efficiency ratings, complaints and grievances filed by or against me; records and recollections of attorney-at-law or of other counsel, whether representing me or any other person (in either a civil or criminal case in which I have been involved); records from the U.S. Veterans' Administration; criminal history information of file in local, state or federal agencies; and motor vehicle records, and following an employment offer, workers' compensation reports from either the Department of Labor, National Personnel Records or the Industrial Commission or similar agencies under the provisions of the Fair Credit Reporting Act 15, USC section 1681 et seq. I also authorize the National Personnel Records Center, or other custodian of my military service record, to release to SBC Forensics, the following information and/or copies of documents from my military service record: DD214, service record, and any disciplinary records.

I understand that these searches will be used to determine work assignment or employment eligibility under the company's employment or volunteer policies. Therefore, I authorize and consent for full release of records (either orally or in writing) to the authorized representatives of the company. In addition, I release and discharge the company and its agent and associates to the full extent permitted by law from any claims, damages, losses, liabilities, costs expenses or any other charge or complaint filed with any agency arising from retrieving and reporting this information. I understand that according to the Federal Fair Credit Reporting Act, I am entitled to know whether employment was denied based upon the information obtained and to receive, upon written request, a disclosure of the background report. I also understand that I may request a copy of the report from my employer. After reading this document, I fully understand its contents and authorize the background verification.

I have read the above and consent to the release and hereby certify that all information provided in this authorization is true, correct and complete. I understand that if any information proves to be incorrect or incomplete that grounds for the canceling of any and all offers of employment or volunteer positions will exist and may be used at the discretion of the employer.

SIGNATURE

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

DATE SIGNED