SUPERVISOR�S INITIALS by r16lFE

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									                                                COBB COUNTY SCHOOL DISTRICT
                                                                  CONSENT FORM

I hereby authorize the Cobb County School District to receive any criminal and/or driver's history record information pertaining to me which may be in
the files of any state or local criminal justice agency. I further give consent to the District to perform periodic criminal history background checks for the
duration of my employment with the District.

I understand that neither the GCIC, its employees, nor any other agency or employees of the State of Georgia shall be responsible for the accuracy of
information nor have any liability for defamation, invasion of privacy, negligence or any other claim in connection with any dissemination of information
pursuant to this record check, and shall be immune from suit based upon any such claims.

I understand that by signing this form, I am attesting that I have disclosed any and all previous Criminal and/or Driver’s history information requested on
the employment application; and that failure to accurately disclose criminal history information and/or any misstatement or omission of any information
requested shall be a reason for non-employment or dismissal from employment.”

All fields are required and must be completed. Driver license information is only applicable for those operating CCSD vehicles or who will potentially
transport students.



PLEASE TYPE OR PRINT THE FOLLOWING INFORMATION: Work Location /                                                         / Position

NAME
                         Last                                           First                                  Middle                (Maiden)

ADDRESS
                                    Street                              City                                              State                  Zip Code

                                                                                                                       -   -
            Sex                     Race                    Date of Birth                                      Social Security Number


LICENSE#                                                    STATE:
      Driver's License No. / State I.D. No.


            Date                                                                                   Signature

                                                                     DO NOT WRITE BELOW THIS LINE
*****************************************************************************************************

                                                        Director, Department of Public Safety
Signature          James D. Arrowood                                Title



                                                                        GA.033 1300        /       Cobb County School District
            Terminal Operator                                           ORI Number             /    Agency


                                                                       ECH ROUTING/CHECK SHEET


________________ Date logged in (Form completed by applicant)


________________ Date faxed to the Department of Public Safety


________________ Returns received from the Department of Public Safety with ECH attached/Director to initial and distribute to
            originator


________________ Date originator verified/logged out
                   Return to Director for appropriate action:


            ________ File
            ________ Sent: NEEDS ADDITIONAL INFORMATION letter
            ________ Sent: DISQUALIFICATION/CRIMINAL HISTORY letter
            ________ Sent: DISQUALIFICATION/FALSIFYING RECORDS letter
            ________ Sent: DISQUALIFICATION/TRAFFIC VIOLATION letter
            ________ Other
                                 Requested by Dr. Michael Shanahan. - Chief Human Resources Officer
GCIC 12/78
F-5:P-4014.139                                                                                                                                  P-4014
Revised 3/89; 6/93; 10/96; 3/99;5/00;5/01;10/01;9/02;1/03;5/03;7/06; 8/06; 05/07; 4/08; 2/12

								
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