Consent Form
Requesting Consumer Reports for Employment Purposes
In connection with my application for employment with Kutztown University of Pennsylvania, (the "Employer"), who may
request consumer reports or investigative consumer reports on me, I understand that these reports may include preemployment credit reports, criminal background (all levels), governmental databases, department of motor vehicle reports,
as well as verifications of professional license, employment (including reason for termination), professional and personal
references, and education verification including copies of my transcripts.
By signing below I give my consent and authorization to this Employer, their screening agent, and any agency contacted in
connection with this application to obtain consumer reports and investigative consumer reports as listed above. I understand
should I be hired by the Employer, that this consent will hold firm throughout my employ with the Employer for use in annual
background checks, promotions and other security related matters deemed as needed by the Employer that require
background screening.
I release and hold harmless any individual, corporation, or private or public entity from any and all causes of action that might
arise from furnishing to the Employer any information or data they may request pursuant to this release.
A photo or faxed copy of this release will act as the original and shall be valid for this and any future reports or updates that
may be requested by the Employer in connection with my employment.
____________________________________________________Date____________________________
Signature
Full Name ____________________________________________________________________________
Print
Names/Aliases/Maiden names used in the past:
_____________________________________________________________________________________
Social Security Number _____________________________________Date of Birth __________________
Driver's License Number ____________________________________State of Issue__________________
Present Address________________________________________________________________________
City, State, Zip _________________________________________________________________________
Position Applying For
_____________________________________________________________________________________
Previous Names, Aliases and Addresses: (List all for the past 5 years) Use back of this sheet if necessary.
_____________________________________________________________________________________
D
Departme
ent of Hu
uman Resources
Kem p Building  4454 Normal Avvenue  Kutzttown PA 19530
0
Pho
one: 610‐683‐1353  Fax: 6610‐683‐4641 
 Email: hum
manresources@
@kutztown.edu
u KUTZTOWN
K
FACULTY P
PROFILE
POSITIO
ON APPLYING FO
OR:
Pleasee check one: DEPARTM
MENT:
Tenurre Track Temporary:
Full-tim
me
FULL NAME (Last, First & Middle):
Part-ttime ASES / MAIDEN N
NAMES:
LIST PREVIOUS / ALIA
STREET
T ADDRESS:
APARTMENT / UNIT #:
CITY
STATE
E
PHONE
E:
ALTE
ERNATE PHONE NUMBER:
N
Have y
you ever work
ked for Kutzto
own University
y:
Are yo
ou a US citizen?
Yes
Yes
ZIP CODE
EMAIL
L ADDRESS:
No If yes, inndicate date oof employmentt and departm
ments below:
No If not, do you have a legal right too work in the U
US? Please ex
xplain below.
Crimin
nal History:
 CRIM
MINAL OFFEN
NSE includes fe
elonies and mis
sdemeanor offe
enses.
 CON
NVICTION is an adjudication of guilt and includes determinations before
e a court, a disstrict justice or magistrate and pleas of nolo
o
conttendre (no conttest) that resultt in a fine, sentence or probattion.
 For this question disregard:
d
mino
or traffic violatio
ons (no points)), offenses com
mmitted before
e your 18th birtthday which we
ere adjudicated
d
in juvenile court un
nder a Youth Offender
O
Law, and
a any charg
ges which have
e been expung
ged by a court or for which yo
ou successfully
y
completed an Acce
elerated Rehab
bilitative Dispos
sition Program..
 A “Y
Yes” answer is not
n necessarily
y a bar to emplo
oyment.
WERE
E YOU EVER CONVICTED
C
OF
O A CRIMINAL OFFENSE?
Yes
No
If you
u answer “Yes”, please provide a written exp
planation in the
e space below.
AG
GREEMENT
Notic
ce of Availabilitty of Annual Se
ecurity Report
This re
eport includes sttatistics for the previous three years
y
concerning
g reported crime
es that occurred
d on-campus; in
n certain off-cam
mpus buildings or
propertty owned or controlled by Kutzto
own University; and
a on public pro
operty within or immediately adj acent to and acccessible from, th
he campus. This
s
report a
also includes ins
stitutional policies concerning campus security, such
s
as policies concerning sexu
ual assault, and other matters. Y
You can obtain a
copy o
of this report by contacting the Department
D
of Public
P
Safety & Police
P
Services at one of the fo
ollowing: Mailing
g address: Kutzztown University
y,
c Safety & Po
olice Services, P.O. Box 730
0 Kutztown, PA
A 19530 Phon e 610-683-4002
2 / Fax 610-6
683-1530 Emaill:
Department of Public
publicssafety@kutztown.edu
I certifyy that all stateme
ents made by me
e on this applica
ation and any supporting materia
al included are trrue and correct tto the best of myy knowledge and
d
belief, a
and are a full and complete discllosure. I agree that
t
if employed, any misreprese
entation or falsificcation regardlesss of when discovvered, shall justify
y
disciplinary action, including termination. I understand
d that Kutztown University
U
will co
onduct a comple
ete background investigation as part of the hiring
g
ze Kutztown Univ
versity of Pennsy
ylvania to contac
ct my previous em
mployers and refferences.
processs. I also authoriz
By SIG
GNING BELOW, I certify that I hav
ve read and agre
ee with these sta
atements.
cant’s Signatu
ure
Applic
Date