BACKGROUND INQUIRIES & SERVICES
PO Box 5804, Cary, NC 27512
(919) 377-0917, fax (919) 893-1495
BACKGROUND INQUIRIES & SERVICES FOR CARTER G. WOODSON SCHOOL
In connection with my application for employment with CARTER G WOODSON SCHOOL, I understand the company may now, or at any time while I am employed, conduct an investigative consumer report containing information on my character, general reputation, personal characteristics, or mode of living.. I am aware I have a right to request, from BACKGROUND INQUIRIES & SERVICES, INC., the nature and scope of the investigative report.
I hereby authorize your company or any agent of your company to contact any and all corporations, former employers, credit agencies, educational institutions, law enforcement agencies, city, state, county, and federal courts and military services to release information about my background including, but not limited to, information about my employment, education, consumer credit history, driving record, criminal record, and general public records history to the person or company with which this form has been filed.
I understand that a Photostat copy of this Authorization will be considered effective and as valid as an original.
Initial here if you wish a free copy of this report mailed to the address you supplied:
REQUIRED DATA - Please print clearly
Full Name:
First Name
Middle Initial
Last Name
Maiden/Other:
Dates Used:
Social Security Number:
Date of Birth:
Driver's License #:
State:
Present Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
List additional addresses for the past 7 years. (Use additional pages if needed)
Prior Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Prior Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Prior Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Prior Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date
-
Month
-
Day
Year
Date
Print Name
Signature
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Phone: (336)723-6838
Address: 437 Goldfloss St.
Winston-Salem, NC, 27127
CRIMINAL BACKGROUND & LICENSING QUESTIONNAIRE
If you answer "YES" to any question, attach a detailed written explanation. If you answer "YES" to any question related to a court proceeding, a certified true copy of the court record must accompany this application. Please do not provide information for records that have been expunged by a court.
CRIMINAL
1. Are you on a child abuse registry or sex offender registry of any kind?
Yes
No
2. Have you ever been, or are you currently being investigated for alleged or suspected child or neglect by any government agency?
Yes
No
3. Have you ever been convicted, pled guilty or pled nolo contendere (no contest) to any criminal offense other than a minor traffic violation (criminal offense includes, but is not limited to a felony, a misdemeanor, driving while impaired). Please include any conviction, regardless of pardon. You must explain relevant circumstances in detail. NOTE: In response to this question, include all offenses other than minor traffic offenses. The following are not traffic offenses and mut be listed: DWI, DUI, Failure to Stop in the Event of an Accident (hit and run) and Driving While License Revoked or Suspended (DWLR).
Yes
No
4. Have you ever received probation, deferred prosecution, or any type of pre-trial adjudication, including a PJC (prayer for judgment) other than for minor traffic offense documentation.
Yes
No
5. Have you ever participated in a diversion program in lieu of prosecution?
Yes
No
6. Have you ever been arrested, indicted or otherwise charged with a crime other than for minor traffic offense regardless of whether you were convicted, or charges were dropped?
Yes
No
7. Are you currently named in a pending criminal charge, indictment or special presentment of any offense other than for a minor traffic offense regardless of whether you were convicted or whether the charges were dropped?
Yes
No
PROFESSIONAL LICENSING
8. Have you ever had a professional certificate, credential, or license of any kind revoked or suspended, or one surrendered prior to its expiration?
Yes
No
9. Have you ever been reprimanded, censured, placed on probationary status by a licensing board, commission or agency for any alleged misconduct or alleged violation of professional standards of conduct?
Yes
No
10. Are there any pending adverse actions or investigations against you relating to a professional certificate, credential, or license in North Carolina or any other state or country?
Yes
No
11. Have you ever been denied a professional license for which you applied?
Yes
No
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CARTER G. WOODSON SCHOOL
Phone: (336)723-6838
Address: 437 Goldfloss St.
Winston-Salem, NC, 27127
12. Have you ever been granted a professional license on a conditional or probationary basis for any alleged misconduct or alleged violation of professional standards or conduct?
Yes
No
13. Have you ever been disciplined by any board, commission or agency responsible for licensure of any kind including, but not limited to, educational licensure?
Yes
No
EMPLOYMENT
14. Have you ever been dismissed from employment by a school system for any reason, or been dismissed or had a contract non-renewed or non-extended by any employer for reasons of misconduct as defined in this application?
Yes
No
15. Have you ever had a disciplinary suspension, or resigned, or been non-rewarded or dismissed following allegations of behavior for misconduct related to your employment or arising out of your employment?
Yes
No
16. Have you ever been, or are you currently being investigated or charged by a licensing board, commission, or agency with a violation of a Professional Conduct of Ethics or any similar code of conducts?
Yes
No
NOTE: For purposes of this application, "misconduct" means the following:
A. Conviction of a crime other than a minor traffic offense
B. Use of excessive or inappropriate force against a minor that causes an observable physical injury
C. Inappropriate interaction with a student of a sexual or romantic nature
D. Theft, embezzlement or fraud related to school funds or property
E. Illegal use of weapons or firearms on school property or at school-sponsored events
F. Use of drugs or alcohol involving students
G. Violation of the State Testing Code of Ethics; and excessive use of alcohol or nonmedical use of a controlled substance as defined in Article 5 of Chapter 90 of the General Statutes, proved that there is a reasonable and adverse relationship between the underlying conduct and the continuing ability of the person to perform any of his/her professional functions in an effective manner
I, _________________________________________________ have read and hereby acknowledge I have answered all questions truthfully.
Printed Name
Date
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Month
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Day
Year
Date
Signature
Submit
Should be Empty: