Consumer Reports Release

In connection with my application with Wake Technical Community College (WTCC), I understand that consumer or investigative consumer reports which may contain public record information, may be requested or made on me including, but is not limited to, consumer credit, criminal records, driving record, education, prior employer verification, social security number verification, workers compensation claims, credit standing, credit capacity, character, general reputation, personal characteristics, trustworthiness and others. These reports will include experience along with reasons for termination of past employment. Further I understand that you will be requesting information from various Federal, State and Local agencies regarding my past activities. I also understand that the information below regarding sex, race and date of birth is requested for the sole purpose of gathering the above information correctly, and will not be used to discriminate against me in violation of any law.

I hereby authorize and consent to WTCC procurement of such a report

I hereby authorize without reservation, any party or agency to furnish the above-mentioned information to WTCC. I understand I have the right to make a request of the Consumer Reporting Agency, upon proper identification and the payment of any authorized fees, the information in its files on me at the time of my request. I further authorize ongoing procurement of the above-mentioned reports at any time during my employment (or contract).

FOR IDENTIFICATION PURPOSES:

Last Name: / First Name: / Middle Name:
Social Security Number : -- / Date of Birth: / Gender: / Female
Other Names (Maiden, Aliases): / Male
Driver’s License Number: Driver’s License State:
Has your driver’s license ever been revoked (If yes, explain):

BACKGROUND VERIFICATION:

Have you ever been convicted of any unlawful offense other than a minor traffic violation? This includes DUI/DWI, worthless checks, violations of local ordinances or state statutes that resulted in a fine or incarceration, misdemeanors, felonies, etc. Guilty verdicts, guilty pleas, prayers for judgment (PJC), and “no-contest” pleas must be included unless the convictions have been expunged from your record. Yes No
**If Yes, list date(s), count(ies), state(s), and specific crime(s) in this box. A previous conviction will not automatically disqualify you from consideration. However, failure to provide complete and accurate information is considered falsification, and your application will be removed from consideration. If currently employed, falsification may subject you to disciplinary action up to and including termination of employment. If you are unsure of your conviction history, please verify prior to answering.
Ethnicity (optional) / Race (optional)
Hispanic / Latino / American Indian or Alaska Native / Hawaiian or pacific Islander
Non Hispanic / Latino / Asian / White
Black or African American / Two or More Races

LIST ALL ADDRESSES FOR THE PAST SEVEN (7) YEARS STARTING WITH THE MOST CURRENT

(Include Street, City, State, Zip, and Dates for each location)

Signature: Date:

HR Use Only: E – Employee P – Pending (candidate not yet hired in system) HR Initials

V – Volunteer

Form 1236 R-5 (4-25-16) LW/HR