AUTHORIZATION OF RELEASE OF CRIMINAL INFORMATION

Position Applied For: ______

To Whom It May Concern:

This will authorize any clerk, officer, judge, custodian or other person to give the Crawford County Public Schools, 190 E. Crusselle Street, Roberta, Georgia, 31078, any and all information in their possession regarding any criminal history or record pertaining to me which may be on file with any criminal justice agency court or the GCIC/NCIC, or other information requested upon presentation of this authorization or any reproduced copy thereof.

Yes No

1 / Have you ever, regardless of how long ago it was, been arrested, convicted, pled guilty, pled nolo contendere, or entered a plea of first offender in any court to any charge of criminal conduct, or been sentenced under any first offender or similar statute, or are you now under investigation for any criminal conduct other than a minor traffic offense? (DUI, DWI, and/or possession or distribution of illegal drugs must also be reported. Exclude only events that occurred when you were a minor unless you were prosecuted as an adult)
2 / Are any charges now pending against you by any federal, state, local, or foreign authority (ies)?
3 / Have you ever been arrested, charged or found guilty of committing any crime involving a child, minor or a person in custody (student)? (includes child abuse)
4 / Have you ever been accused, investigated, arrested, charged, convicted or pled to a lesser offense for any sexual offense, including sexual harassment?
5 / Have you ever had any adverse action taken against a license, permit, credential, or certificate issued by any State agency, or had one denied, revoked, or suspended, or is any investigation or adverse action now pending against you?(Adverse actions may include, but are not limited to: warning, reprimand, probation, suspension, revocation, denial, voluntary surrender, disbarment, etc.)
6 / Have you ever retired, resigned, been dismissed, terminated or otherwise separated from employment (including Armed Forces) while under investigation for the commission of a felony and/or a misdemeanor or for allegations of a violation of a professional code of ethics, laws, rules, or standards?
7 / Have you ever received probation or deferred judgment or had to complete/participated in a pre-trail diversion or program?
8 / Have you ever served a sentence in a jail or state penitentiary for any crime?
9 / Have you ever been arrested, charged, or convicted of any traffic violations?
10 / Have you ever been investigated, arrested, charged, convicted or pled to a lesser offense for a crime of involving abuse or neglect?(Including child abuse, physical abuse, etc.)

Numbers11-16 to be completed by Transportation & Maintenance Applicants

11 / Have you ever been denied a driver’s license or permit?
12 / Has your driver’s license or permit ever been suspended, revoked or cancelled?
13 / Have you ever been arrested, charged or convicted of any traffic violations?
14 / Do you now have or have you ever had restrictions placed on your driver license or permit?
15 / Have you ever had a “driving while intoxicated” charge or a “driving while influenced” charge?
16 / Have you ever lost your job because of your driving record?

BY SIGNING BELOW I ATTEST THAT THE ABOVE IS TRUE AND ACCURATE.FALSIFICATION OF THIS INFORMATION MAY RESULT IN NON-EMPLOYMENT.

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NAME (PLEASE PRINT)

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STREET ADDRESSCITYSTATEZIP CODE

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SEXRACEDATE OF BIRTH SOCIAL SECURITY DRIVERS LICENSE NUMBER

______

SIGNATURE DATESworn to and subscribed before me this

______day of ______

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NOTARY PUBLIC

Revised : 5/03/11 DL