VSUPD: Please return results to:
Human Resources
V.P.A.A.
Student Employment
VALDOSTA STATE UNIVERSITY
APPLICANTS CONSENT TO BACKGROUND INVESTIGATION
(revised 07/01/08)
I hereby authorize Valdosta State University Police Department and the hiring agent(s) of Valdosta State University for the
purpose of employment consideration to receive any information regarding: criminal history, education verification, sexual offender
status, motor vehicle record, employment references, drug screening, or credit record check, where applicable, and which may involve
public record or various federal, state or local agencies. This list is not all inclusive.
Please use black or blue ink only.
Full Name _____________________________________________________________________________________________________
Address _______________________________________________________________________________________________________
City ___________________________ State ______________________ Zip ___________________________
Date of Birth_______________________________ Social Security Number ____________________________________
Place of Birth: City _________________County __________________ State/Province ______________ Country _______________
Driver’s License Number ____________________________________ State of Issue __________________________
Sex: Male
Female
Race: Black Asian
Native American
White
Hispanic
Other (specify) ______________________
Physical Description: Height ___________ Weight _____________ Eye Color ______________
INSTRUCTIONS – Please Read
Read the following carefully and answer truthfully, if you have been convicted of a crime, you may not be automatically disqualified
from consideration for employment. GIVING FALSE OR INCOMPLETE INFORMATION IS SUFFICIENT CAUSE TO
DISQUALIFY YOU FROM EMPLOYMENT. If you are not sure of the court disposition of a case, list all other information
requested.
Have you EVER been convicted of a crime, paid a fine, forfeited a bond, been sentenced (by a judge) to perform community service, pled
no lo contendere (no contest), pled guilty, been given a suspended sentence, or been sentenced to jail or prison time? (Include DUIs, but
DO NOT include minor traffic offenses, juvenile cases, cases sealed or expunged by a court, or case completed under the First Offender
Act.)
Yes
No
DO NOT ASSUME CHARGES OR CONVICTIONS HAVE BEEN REMOVED.
If the answer is YES to any of the above, list all information requested below. (Please use additional sheets if necessary.)
Charge/Offense
Date
Arresting Agency/Location
Court Disposition
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
Having read all of this form, I give Valdosta State University my consent to conduct the investigation and release all persons from any
and all liability with respect to said investigation. The information will be disclosed only to Human Resources employees and persons(s)
responsible for making hiring decisions.
Signature _________________________________________________________ Date ______________________________________
Notary Public ___________________________________________________ My commission expires _________________________
Department ____________________________________
Department Contact __________________________________________
Form revised 7/1/08
For Criminal Background Checks:
This information is current and valid as of the date of review:
Date Checked: _________________ Report Reviewed by: ___________________________________________
Dept:________________________ Title:_________________________________________________________
For Credit Report Checks:
Eligible
Ineligible
This information is current and valid as of the date of review
Date Checked: _________________ Report Reviewed by: ___________________________________________
Dept:________________________ Title:_________________________________________________________
Other Background Checks Appropriate to the Position:
Type:_________________________________________
Eligible
Ineligible
This information is current and valid as of the date of review
Date Checked: _________________ Report Reviewed by: ___________________________________________
Dept:________________________ Title:_________________________________________________________
Additional Information _______________________________________________________________________:
__________________________________________________________________________________________
__________________________________________________________________________________________
For V.P.A.A./Human Resource’s Use:
Date Received: __________________________
_______ Eligible
_______ Ineligible
Date Applicant Notified: __________________________
Date Employing Department Notified: _________________________ V.P.A.A./HR Initials: ___________________