Welcome to the University of North Carolina at Chapel Hill!

We appreciate your interest in serving as a volunteer, unpaid intern or unpaid visiting scholar and supporting the University’s mission of teaching, research, and public service. Because individuals serving in unpaid positions may be required to interact with other members of the University community as well as campus visitors and may also have access to University facilities, it is the policy of the University to perform background checks on all such individuals to enhance campus safety. The background check determines if you have any prior criminal convictions that would be incompatible with your proposed assignment. This is for the benefit of our entire campus community and we appreciate your understanding and cooperation with this important safety requirement.

While a prior criminal conviction does not automatically bar service to the University, in the event there is a prior criminal conviction which would prevent us from approving your proposed service or altering the nature of this service, we will provide you with the specific information we have relied on to make this decision and its source so that you have an opportunity to review its accuracy and to pursue any correction if applicable. Your social security number (SSN) is being requested by the University to conduct a residence history and criminal conviction background check consistent with University policy. You are not required to disclose your SSN, however, if you do not disclose SSN, you will not be considered for an unpaid assignment with the University.

The information provided on this form will be treated confidentially and only University officials who need this information to satisfy the background check process will have access to it.

Thank you again for your service to UNC-Chapel Hill.

The University of North Carolina at Chapel Hill

Volunteer/Unpaid Intern/unpaid visiting scholar background check form

please provide the following information:
First Name / Middle Name / Last name / Maiden
Social Security # / Date of Birth / sex / race


If you have been known by other names, please list them here:

Name / dates used / name / dates used
CURRENT RESIDENCE (street, city, state, zip):
IF CURRENT RESIDENCE IS NOT PERMANENT, GIVE PERMANENT RESIDENCE (If permanent address is a non-U.S. address, also include country):


If you have lived or worked outside of North Carolina during the past ten (10) years, please list the States, dates lived or worked in those locations, cities, counties, and the name(s) used during those times. If you have not lived or worked outside of the State of North Carolina in that time frame, providing your current residence above is sufficient.

STATE / DATES
(YR TO: YR) / CITY / COUNTY / LAST NAME(s) USED
Have you been convicted of an unlawful offense as an adult? If yes, list below the county, state, and date of the conviction and crime/offense for which you were convicted. Prayers for Judgment Continued (PJCs) and non-contested charges must be included, unless you have acted to expunge your record. If more space is needed, check here and attach additional pages.
Date / Location (county and state) / Crime/Offense

I hereby certify that all information I have provided on this Authorization is true and complete to the best of my knowledge and belief. I understand that electronic submission of my Authorization indicates my consent to the University’s verification of any information contained in this Authorization, including by obtaining a consumer report for employment/appointment purposes from a Consumer Reporting Agency. I understand that by admitting to a conviction for any unlawful offense, I will not be disqualified automatically from consideration for unpaid appointment. I understand that false or misleading information or documentation, or an omission or failure to include all relevant information, may result in not being appointed or termination of my affiliation with the University.

Appointee Signature / Date
The following page is for University use only


The University of North Carolina at Chapel Hill

Volunteer/Unpaid Intern/unpaid visiting scholar background check form

TO BE COMPLETED BY APPOINTING DEPARTMENT:
FIRST / GIVEN MIDDLE / LAST / SSN

ensure that all sections are completely filled before submitting to background investigator. incomplete forms will be returned to the requesting department’s contact to be completed.

Driving a personal motor vehicle is required by appointing department to perform assigned duties. (If answer is yes, a driver’s license check is required – fill in driver’s license information below.)* / Yes
No
Appointee’s Drivers License Number / Issuing State

* IMPORTANT: In those limited circumstances where operating a State-owned motor vehicle has been authorized by the relevant University offices, the appointing department must contact OHR Employment and Staffing to have a separate driver’s license check completed prior to the individual having access to or driving any such vehicle.

activity TYPE: / VOLUNTEER
UNPAID intern
VISITING SCHOLAR
CONTACT NAME:
DEPT/SCHOOL NAME AND NUMBER:
CONTACT PHONE #:
CB #:
ACCOUNT # FOR FEE:
OHR EMPLOYMENT CONSULTANT:

·  Send this form to your Employment Consultant at the following address:

Office of Human Resources

Employment and Staffing, CB# 1045

TO BE COMPLETED BY THE OFFICE OF HUMAN RESOURCES
Date received: / Date performed:
No criminal conviction(s) found.
Criminal issue(s) found; agree(s) with authorization form.
Criminal issue(s) found; do(es) not agree with authorization form.
Possible criminal record found; further review needed.
Valid Driver’s License confirmed.
Driving record clear.
Driving issue(s) found; agree(s) with authorization form.
Driving issue(s) found; do(es) not agree with authorization form.
Possible driving record found; further review needed.
Charge made to the listed account.
INIT: / FILE#:
Date returned:
Checks COMPLETED:
CoURT Search / Castle Branch* / Sex offender
nc dl check / out of state dl / AOC
Journal Entry#:
Date entered:
Amount Due: / No CS Results

* Federal and Out of State included.

Rev (03-22-2012) Equal Opportunity Employer Page 2 of 3