HR Background Check Authorization

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Academic Affairs
7000 Mercy Road
Omaha, Neb. 68106
Phone: 402-399-2693
Email: academicaffairs@CSM.edu

BACKGROUND REPORT AUTHORIZATION FORM

In connection with my application for employment, I understand that a background report may be requested which may include information as to my character, background, mode of living, personal reputation, work habits, performance, experience, and reasons for termination of past employment. I also understand information from public and private sources about my workers’ compensation injuries, driving record, court records, education, credentials, credit and references may be requested.

This document permit’s the release of any information to Secured Data Services, agent of College of Saint Mary. I hereby authorize and release from any liability, any law enforcement agency, institution, information service bureau, school, employer, personal reference, College of Saint Mary or its agent, Secured Data Services.

Nursing adjunct faculty should note that signing this authorization also indicates your consent to the following:
     I authorize College of Saint Mary to process my name through the National Sex Offender/Predator Watch List. (NSOPW).
     I authorize College of Saint Mary to conduct an Iowa Criminal History record check and an Iowa Abuse Registries check.
     Background report results may be forwarded to appropriate clinical facilities when requested.

SECTION I. PERSONAL INFORMATION

Please print all information. The following information is needed to match identities with records.

Last Name:

First Name:

Middle Name:

Other Name(s) Used:

Date of Birth (MM/DD/YYYY):

Gender:

SSN (###-##-####):

CURRENT ADDRESS:

Street Address:

City:

State:

Zip:

PRIOR ADDRESS:
(if any others within the last ten (10) years)

Street Address:

City:

State:

Zip:

SECTION II. AGREEMENT AUTHORIZATION

COLLEGE OF SAINT MARY, 7000 Mercy Rd., Omaha, NE 68106

The applicant's signature is required.

Electronic signature

Please read the Disclosure/Consent before you sign your form electronically.

Typing your name below signifies you are completing this form using an electronic signature. By signing electronically, you are certifying that you have read and understand the Disclosure/Consent and agree to electronically sign. You also agree to receive required disclosures or other communications related to this transaction electronically.

To continue with the electronic signature process, please enter your name and click "Submit" below to submit this form with your electronic signature.

First Name:

Last Name:

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