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Pre Employment Background Check Authorization - DOC

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									                                     The University of North Carolina at Chapel Hill
                          AUTHORIZATION FOR PRE-EMPLOYMENT BACKGROUND CHECK

TO BE COMPLETED BY THE CANDIDATE/APPOINTEE

FIRST                            MIDDLE                             MAIDEN                           LAST


SOCIAL SECURITY # *              DATE OF BIRTH                      SEX                              RACE


* Your social security number 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 social security number; however, if
you do not disclose your social security number you will not be considered for employment.

Please list all other names by which you have been known, along with the dates each name was used:
NAME                             DATES USED                          NAME                             DATES USED




NC DRIVERS LICENSE #                                         I have held an out-of-State drivers license that has been        YES
(if required for position)                                   valid within the last 12 months.                                 NO
If the answer is yes, provide the following information:     License #                               Issuing State

CURRENT RESIDENCE (street, state, zip):
IF CURRENT RESIDENCE IS NOT PERMANENT,
GIVE PERMANENT RESIDENCE (street, state, zip):

   Yes         No    Are you currently an employee of the University of North Carolina at Chapel Hill?
   Yes         No    Have you ever lived or worked outside of North Carolina? If yes, complete page 2 of this form.
   Yes         No    Have you ever been convicted of an unlawful offense? 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 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 employment. I understand that false or misleading information or documentation, or an
omission or failure to include all relevant information, may result in rejection of my application, action up to and including
termination if hired, and/or criminal prosecution. If hired, I understand the University complies with State law and is required to
terminate me if false or misleading information is given in order to meet the requirements for the position involved.



______________________________________________                    ________________________________________________
  Candidate/Appointee Signature                                            Date
                                                                                    Candidate section continued on next page

Rev (11-12-2010)                                     Equal Opportunity Employer                                             Page 1 of 3
                                   The University of North Carolina at Chapel Hill
                         AUTHORIZATION FOR PRE-EMPLOYMENT BACKGROUND CHECK

TO BE COMPLETED BY THE CANDIDATE/APPOINTEE

CANDIDATES: If you have lived or worked outside of North Carolina, please list the States, dates lived or worked in those
            locations, cities, counties, and the name(s) used during those times.

FIRST                          MIDDLE                          LAST                            SSN (LAST 4 DIGITS)
                                                                                               XXX-XX-

                                                                                    LAST NAME(s) USED AT EACH
 STATE       DATES (YR TO: YR)                 CITY                COUNTY
                                                                                    LOCATION (if different from above)
Example:     2001-2010                  Chapel Hill          Orange                 Smith
NC




TO BE COMPLETED BY THE DEPARTMENT OF PUBLIC SAFETY

OTHER LOCATIONS DISCOVERED IN COURT SEARCH:
                                                                                    LAST NAME(s) USED IN EACH STATE
STATE      DATES (YR TO: YR)                  CITY                COUNTY
                                                                                    (if different from above)




Rev (11-12-2010)                                  Equal Opportunity Employer                                         Page 2 of 3
                                      The University of North Carolina at Chapel Hill
                           AUTHORIZATION FOR PRE-EMPLOYMENT BACKGROUND CHECK

FIRST                            MIDDLE                          LAST                               SSN (LAST 4 DIGITS)
                                                                                                    XXX-XX-
TO BE COMPLETED BY HIRING DEPARTMENT

                                                                                                                         YES
Driving a motor vehicle is required by the hiring department for the employee to perform their assigned duties
                                                                                                                         NO
                                                                                                                         YES
The employee will be expected to drive a University-owned vehicle in the performance of their duties
                                                                                                                         NO

                                                     FACULTY
                                                                                    SPA PERMANENT
                                                     EPA NON-FACULTY
   POSITION/ APPOINTMENT TYPE:                                                      SPA TEMP
                                                     POST DOC
                                                                                    OTHER
                                                     EPA TEMP
POS/APPT TITLE:                                  Example: Admin. Support Spec.
POS# (SPA ONLY):                                 Example: 0055555
CONTACT NAME:
DEPT/SCHOOL NAME AND NUMBER:                     Example: Dept of H.R./2228
CONTACT PHONE #:
CB #:
DATE SENT TO DPS: (ignore for faculty)
ACCOUNT # FOR FEE
OHR EMPLOYMENT CONSULTANT:

  For SPA Permanent employees, please send this form to your Employment Consultant.
  For Faculty, please send this form to the Dean’s Office.
  For EPA-NF and temps, please send to:

                   Background Investigator
                   UNC Public Safety
                   AOB, Suite 2300, CB# 1620
                   Fax: 919-962-4279

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.

TO BE COMPLETED BY THE DEPARTMENT OF PUBLIC SAFETY

DATE RECEIVED:                                                              Date check performed:            ______
                                                                                    No criminal conviction(s) found.
DATE RETURNED:
                                                                                    Criminal conviction(s) found; agrees with
COMPLETED CHECKS:                                                                   application. See attached.
                                                                                    Criminal conviction(s) found; does not agree
AOC                       CASTLE BRANCH*         COURT SEARCH                       with application. See Attached.
SEX OFFENDER              NC DL CHECK            OUT OF STATE DL                    Valid Driver’s License Confirmed.
JOURNAL ENTRY#                                                                      Clear Driving Record

DATE ENTERED                                                                        Driving record contains possible issues,
                                                                                    please review attached results for details
NOTES:                                                                              Charge made to the listed account.
                                                                            INIT:                FILE#:

* Federal and Out of State included


Rev (11-12-2010)                                   Equal Opportunity Employer                                               Page 3 of 3

								
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