roxbury

DISCLOSURE AND AUTHORIZATION

IMPORTANT - PLEASE READ CAREFULLY BEFORE SIGNING AUTHORIZATION
DISCLOSURE REGARDING BACKGROUND INVESTIGATION

Complete form below and click submit at bottom

Roxbury Community College may obtain information about you for employment purposes from a third party consumer reporting agency. Thus, you may be the subject of a "consumer report" and/or an "investigative consumer report" which may include information about your character, general reputation, personal characteristics, which can involve professional interviews with current and past employers. These reports may contain information regarding your credit history, criminal history, social security verification, motor vehicle records ("driving records"), verification of your education or employment history, or other background checks. Credit history will only be requested where such information is substantially related to the duties and responsibilities of the position for which you are applying. You have the right, upon written request made within a reasonable time, to request whether a consumer report has been run about you, and disclosure of the nature and scope of any investigative consumer report and to request a copy of your report. Please be advised that the nature and scope of the most common form of investigative consumer report obtained with regard to applicants for employment is an investigation into your education, employment history, and criminal background check. The scope of this notice and authorization is all-encompassing, thereby allowing the Company to obtain from any outside organization all manner of consumer reports and investigative consumer reports. .

ACKNOWLEDGMENT AND AUTHORIZATION

I acknowledge receipt and review of this DISCLOSURE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT (provided on next page) and certify that I have read and understand both documents. I hereby authorize the obtaining of "consumer reports" and/or "investigative consumer reports" by the College at any time after receipt of this authorization. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau, employer, or insurance company to furnish any and all background information requested by Carey Consultants, another outside organization acting on behalf of the College, and/or the College itself. I agree that a facsimile ("fax"), electronic or photographic copy of this Authorization shall be as valid as the original. Further, I hereby release ROXBURYCOMMUNITY COLLEGE and any outside organization acting on behalf of the College, of any liability and responsibility in securing and compiling this background investigation and utilizing the information to assist them in making a hiring decision.

I UNDERSTAND FURTHER THAT ALTHOUGH THIS IS A BACKGROUND CHECKING FORM AND NOT AN EMPLOYMENT APPLICATION, FALSIFYING ANY INFORMATION ON THIS FORM CAN LEAD TO MY IMMEDIATE DISMISSAL OR DISCONTINUATION OF MY CANDIDACY FOR ANY POSITION, CONTRACTING ASSIGNMENT, PROMOTION OR TRANSFER.

Digital Signature Release
A value is required.    Today's Date: A value is required.
Type Full Name - Equivalent to handwritten signature
(required)



Section I: Candidate DATA
Last name
A value is required. (required)
First name
 A value is required. (required)
Middle Int
Date of Birth
 A value is required. (required)
Email Address
A value is required.  (required)
Social Security #
 A value is required. (required)
Alias Please indicate any other last names used & years they were utilized:
Street address
A value is required.
City
 A value is required. (required)
State/Zip
A value is required. (required)
Home/cell Phone
A value is required. (required)
Have you been terminated from any place of employment within the past 7 years?
 (required)
Please make a selection.
If yes, indicated place of employment, cause for
discharge & month/year this termination took place:
Please list addresses for the past 10 years:
1.
2.
3.


Section II: Employers DATA - COMPLETE EMPLOYMENT HISTORY REQUIRED - LIST ALL EMPLOYERS
Most recent Employer (required)
 A value is required.
Complete Address (required)
 A value is required.(required)
Dates of Employment
to
Your title
Supervisor’s name (required) A value is required.

Employer Phone number (required) A value is required.

Reason for leaving
If you are still presently employed, may we contact?
 Yes     No
2nd Employer
Complete Address
Dates of Employment
 to
Your title
Supervisor’s name

Employer Phone number

Reason for leaving
3rd Employer
Complete Address

Dates of Employment
 to
Your title
Supervisor’s name

Employer Phone number

Reason for leaving
Please list 3 PROFESSIONAL references (example; supervisors, professional colleagues, etc):
1st reference- Company
Relationship
Telephone
2nd reference- Company
Relationship
Telephone
3rd reference- Company
Relationship
Telephone

Have you been terminated from any place of employment within the past 7 years? 

Yes     No

If yes, indicated place of employment, cause for discharge & month/year this termination took place:
Section III: Driver's Information
Driver's License #
 A value is required. (required)
State issued
 A value is required. (required)
Has your license ever been revoked or suspended?
(required)
Please make a selection.

If yes, explain dates & Circumstances:

If you do not have a driver’s license, please explain why not:
Have you ever been convicted of a crime other than a minor traffic violation?
Yes     No
If yes, please explain, giving dates, locations & circumstances
Section IV: Education
Please list the most recent school, college; professional school or trade school you attended:
A value is required. (required)
Institution name & location
 A value is required.  (required)
Degree/Yr earned:
  If you only attended & received no degree, please list dates of attendance:
Please indicate any further education you feel is relevant to the position for which you are applying:
Section V: Military Experience
Branch
Rank
  
Dates
to
Did you receive an Honorable Discharge
 Yes     No
If not, please explain:
  
Please list any former last names & years used:
  

(Empty Required Fields will display in RED)
By clicking the "Submit" you consent to terms stated above.

You will now be redirected to read the Fair Credit Reporting Act
(Please complete and submit to finish application)