Disclosure And Consent Form For Background Investigation Pers_Disclosure_and_Consent 1Section 12Section 23Section 34Section 4 Requirement to Disclose: If you answered “YES” to question 5E and/or 5F of the Application for Civil Service Exam/Vacant Position, you must submit court documentation and complete this Disclosure and Consent Form for Background Investigation. A “YES” answer to question 5E and/or 5F will not necessarily disqualify you. Each case is evaluated on an individual basis in relation to the duties and responsibilities of the position for which you have applied.Section 1Last Name(Required) First Name(Required) Middle (If Applicable) Position Applying for(Required) Address(Required) City(Required) State(Required) Zip(Required) Telephone(Required) Date of Birth(Required) MM slash DD slash YYYY Social Security Number(Required) Former Names/aliases/a.k.a (If Applicable) Page 1 NOTE: You will be able to attach any additional documents and information in Section 4.Section 2: Removal from Employment ExplanationWere you ever dismissed from any employment for reasons other than lack of work?(Required)YesNoInstructions: Start with your current or most recent dismissal first and work your way backward. Omission, vagueness or fabrications will not be interpreted in your favor. Name of Employer(Required) Address(Required) Job Title(Required) Dates of EmploymentFrom Mo.(Required) Yr.(Required) To Mo.(Required) Yr.(Required) Reason(s) for removal from employment(Required)Further explanation(Required)Name of Employer Address Job Title Dates of employmentFrom Mo. Yr. To Mo. Yr. Reason(s) for removal from employmentFurther explanationName of Employer Address Job Title Dates of employmentFrom Mo. Yr. To Mo. Yr. Reason(s) for removal from employmentFurther explanationAdditional Removals from Employment (if applicable):Page 2 NOTE: You will be able to attach any additional documents and information in Section 4.SECTION 3: Conviction and/or Pending Charges ExplanationHave you ever been convicted of a felony or misdemeanor?(Required)Include sealed records (except as allowed under CPL-170), convictions even if over 10 years ago, and youthful offender records when applying for law enforcement and/or mental health positions. You may omit traffic violations.YesNoInstructions: Start with your most recent conviction first and work your way backward. You must also submit court documentation. Omission, vagueness or fabrications will not be interpreted in your favor. Name of Crime(Required) Type(Required) Misdemeanor Felony Date of Crime(Required) Name and Location of the Court(Required) Adjudication(Required) Guilty Not Guilty Dismissed Year Convicted (if not pending):(Required) Age at Time of Offense(Required)Name Offense Committed Under (if different than current): Explain the circumstances of the offense(Required)List all evidence that exists regarding your rehabilitation(Required)Explain why your conviction(s) and/or pending charges will not affect your fitness to perform the duties and responsibilities related to the position applied for(Required)Explain why your conviction(s) and/or pending charges will not be a hindrance to the County’s legitimate interest in protecting property, and the safety and welfare of specific individuals or the general public(Required)Name of Crime Type Misdemeanor Felony Date of Crime Name and Location of the Court Adjudication Guilty Not Guilty Dismissed Year Convicted (if not pending): Age at Time of OffenseName Offense Committed Under (if different than current): Explain the circumstances of the offenseList all evidence that exists regarding your rehabilitationExplain why your conviction(s) and/or pending charges will not affect your fitness to perform the duties and responsibilities related to the position applied forExplain why your conviction(s) and/or pending charges will not be a hindrance to the County’s legitimate interest in protecting property, and the safety and welfare of specific individuals or the general publicName of Crime Type Misdemeanor Felony Date of Crime Name and Location of the Court Adjudication Guilty Not Guilty Dismissed Year Convicted (if not pending): Age at Time of OffenseName Offense Committed Under (if different than current): Explain the circumstances of the offenseList all evidence that exists regarding your rehabilitationExplain why your conviction(s) and/or pending charges will not affect your fitness to perform the duties and responsibilities related to the position applied forExplain why your conviction(s) and/or pending charges will not be a hindrance to the County’s legitimate interest in protecting property, and the safety and welfare of specific individuals or the general publicAdditional Convictions and/or Pending Charges (if applicable):Note: You must attach court documentation in Section 4 for each conviction and/or pending charge.Page 3 SECTION 4: Certification and Authorization to Access Additional InformationBy my signature below, I,Full Legal Name(Required) (Type Your Full Legal Name), certify that information I provided on this form and any attachments is true, correct and complete. I understand that providing false or incomplete information or withholding by omission or intention pertinent information may be cause for disqualification of my application for employment. I understand that the County of Cortland may contact other individuals to clarify and verify information supplied on this form. I acknowledge and consent to a State and national criminal background investigation, which will include a fingerprint check to determine suitability for employment. Failure to meet the standards of the background investigation may result in disqualification. I authorize law enforcement agencies, learning institutions (including public and private schools and universities), courts (federal, state and local), motor vehicle records agencies, my past and present employers, the military and other individuals and sources to furnish any and all information on me that is requested by the County of Cortland. I agree that this Authorization form in original, faxed, photocopied or electronic (including electronically signed) form will be valid for any reports that may be requested by or on behalf of the County of Cortland. I acknowledge that I have read, understood and agreed freely to the requirements, consents, and authorizations. Upload attachments here (court documentation, termination letter etc.) Drop files here or Select files Accepted file types: pdf, doc, ppt, pptx, odt, docx, txt, Max. file size: 2 MB. Signature(Required) Date(Required) MM slash DD slash YYYY Page 4
