TCSC Background Check Authorization Form

Tri-County School Corporation Supplement to Employment Application

Request for Background Information
Dear Applicant:

Jobs with the Tri-County School Corporation involve contact with our student population. We ask that you complete the questions below to help us evaluate your suitability to work with these students. All applicants for employment are expected to provide us with this information; you are not being singled out for closer inspection. This insert is part of the application itself and any misrepresentation or omission of fact may be grounds for disqualification from further consideration or for termination from employment regardless of when the misrepresentation of omission is discovered.

The conviction of a crime or any affirmative answer provided by you on this insert is not an automatic bar to employment. The School District will consider the nature of any conviction or alleged conduct underlying the affirmative response, the date of the alleged conduct underlying the affirmative response and the position for which you are applying.
Full Name *

Prefix First Name Middle Name Last Name Suffix

1. If you are now working, is your conduct as an employee or the quality of your work the focus of any investigation by your current employer? *

Yes No
If yes, explain the circumstances.
2. Have you ever resigned form a job after being disciplined by your employer or after being offered the opportunity to resign rather than be terminated? *

Yes No
If yes, explain the circumstances.
3. Have you ever been investigated for, charged with or plead guilty or "no contest" to any crime involving the sexual abuse of any person or indecency with a minor? *

Yes No
If yes, explain the circumstances.
4. Have you ever been charged with a crime, other than a minor traffic offense, where the court has deferred further proceedings without entering a finding of guilt and placed you on probation or in a public service or education program? *

Yes No
If yes, explain the circumstances.
Authorization and Release
I authorize the School District to check my employment history, including without limitation, reference checks, and to seek the release of investigatory information, including a "limited criminal history", possessed by any private or public employer or any local, state, or federal agency. I authorize these private or public employees or local, state, or federal agencies to provide the School District any infomration they may release concerning the matters described herin, and I will cooperate to the extent necessary to obtain the release of this information.
I EXPRESSLY WAIVE IN CONNECTION WITH ANY REQUEST FOR, OR PROVISION OF SUCH INFORMATION, ANY CLAIMS OR CAUSES OR ACTION, INCLUDING WITHOUT LIMITATION, DEFAMATION, INFLICTION OR EMOTIONAL DISTRESS, INVASION OF PRIVACY, OR INTERFERENCE WITH CONTRACTUAL RELATIONS THAT I MIGHT OTHERWISE HAVE AGAINST THE SCHOOL DISTRICT, IT'S OFFICIALS, EMPLOYEES, TRUSTEES, OR AGENTS, OR AGAINST ANY PROVIDER OF SUCH INFORMATION.

I HAVE READ THIS AUTHORIZATION AND RELEASE OF ALL CLAIMS, AND I EXPRESSLY AGREE TO THE TERMS SET OUT HEREIN.
Signature *

Clear
Date signed *

Month Day Year
Date
TRI-COUNTY SCHOOL CORPORATION IS AN EQUAL OPPORTUNITY EMPLOYER.
Please verify that you are human *
Should be Empty:

Tri-County School Corporation Supplement to Employment Application