AUTHORIZATION TO CONDUCT INTERN OR VOLUNTEER CRIMINAL HISTORY & BACKGROUND CHECK PERSONAL DATA (Please Print) NAME: SSN: STREET ADDRESS: COUNTY: CITY: STATE: ZIP CODE: DATE OF BIRTH: PLACE OF BIRTH: SEX: RACE: HEIGHT: WEIGHT: JOB TITLE: PROGRAM/OFFICE: SECTION/UNIT: PLEASE LIST ANY PENDING CHARGES AND CONVICTIONS NOT LISTED ON THE SECURITY QUESTIONNAIRE LOYALTY OATH. My signature below evidences my understanding that I am working with the Department of Public Health in the capacity of an intern or volunteer and that a criminal history and financial background check will be conducted on me. I further understand that I am required to disclose the following information in connection with the criminal history background check: any arrest, charge or conviction for any crime other than minor traffic offenses. This includes any drug-related charges and any charges relating to driving while under the influence. I also understand that if I fail to disclose such information and falsify documents that I will be disqualified from further association with the Department of Public Health. I hereby consent to and authorize the Department of Public Health to request and receive any criminal history and financial information pertaining to me, which may be in the files of any federal, state or local agency or credit bureau. This authorization is valid for 90 days from date of signature. Signature of Intern or Volunteer Date SWORN TO AND SUBSCRIBED BEFORE ME: This day of , 20____ (Notary Public Signature and Seal) My commission expires
AUTHORIZATION TO CONDUCT INTERN OR VOLUNTEER CRIMINAL HISTORY & BACKGROUND CHECK PERSONAL DATA (Please Print) NAME: SSN: STREET ADDRESS: COUNTY: CITY: STATE: ZIP CODE: DATE OF BIRTH: PLACE OF BIRTH: SEX: RACE: HEIGHT: WEIGHT: JOB TITLE: PROGRAM/OFFICE: SECTION/UNIT: PLEASE LIST ANY PENDING CHARGES AND CONVICTIONS NOT LISTED ON THE SECURITY QUESTIONNAIRE LOYALTY OATH. My signature below evidences my understanding that I am working with the Department of Public Health in the capacity of an intern or volunteer and that a criminal history and financial background check will be conducted on me. I further understand that I am required to disclose the following information in connection with the criminal history background check: any arrest, charge or conviction for any crime other than minor traffic offenses. This includes any drug-related charges and any charges relating to driving while under the influence. I also understand that if I fail to disclose such information and falsify documents that I will be disqualified from further association with the Department of Public Health. I hereby consent to and authorize the Department of Public Health to request and receive any criminal history and financial information pertaining to me, which may be in the files of any federal, state or local agency or credit bureau. This authorization is valid for 90 days from date of signature. Signature of Intern or Volunteer Date SWORN TO AND SUBSCRIBED BEFORE ME: This day of , 20____ (Notary Public Signature and Seal) My commission expires
GC-09006E-Intern-and-Volunteer-Conduct-Criminal-History-Background.docx