CONSENT FOR RELEASE OF INFORMATION DHS Policy #504 Double-click on the boxes below to indicate your consent. Consent must be granted for each entry. Yes I hereby give my consent for a criminal history Yes I understand that this is a preliminary check for employment purposes and that all prior arrest information will be reported by the Georgia Crime Information Center (GCIC) to the Office of Human Resource Management and Development in the Department of Human Services (DHS). Yes I understand that information received from the criminal history record check may be used as a basis for removing me from consideration for employment or separation from employment. Yes I understand that if I am offered employment with DHS, my fingerprints will be taken and a more extensive background check will be completed. Yes I understand that failure to disclose any prior convictions will be grounds for disqualification from further consideration or termination of employment with DHS. Yes I understand that this consent is voluntary; however, I acknowledge that refusal to give this consent will remove me from further consideration for the position for I applied. Yes In addition to the Criminal History Background check, I give consent to the completion of a comprehensive background check including but not limited to education verification, Integrated Data System (IDS) and reference checks. Yes I also acknowledge that providing false information or failure to disclose any information pertaining to my identity or criminal history may be a violation of O.C.G.A §16-10-20 (False statements and writings, concealment of facts, and fraudulent documents in matters within jurisdiction of state or political subdivisions). Applicant’s Last, First, Middle Name Street Address or PO Box City, State, Zip Code Social Security Number Date of Birth City & State of Birth Gender Height Weight Eye Color College/University City & State Major Degree Graduation Full Name on Degree Date Signature of Applicant Date Name of DHS Organizational Unit Contact Person Number Email Address FOR USE ONLY: No criminal history found through GCIC system check. Criminal history found that prohibits hiring (See attached). Criminal history that does not prohibit hiring (See attached).
CONSENT FOR RELEASE OF INFORMATION DHS Policy #504 Double-click on the boxes below to indicate your consent. Consent must be granted for each entry. Yes I hereby give my consent for a criminal history Yes I understand that this is a preliminary check for employment purposes and that all prior arrest information will be reported by the Georgia Crime Information Center (GCIC) to the Office of Human Resource Management and Development in the Department of Human Services (DHS). Yes I understand that information received from the criminal history record check may be used as a basis for removing me from consideration for employment or separation from employment. Yes I understand that if I am offered employment with DHS, my fingerprints will be taken and a more extensive background check will be completed. Yes I understand that failure to disclose any prior convictions will be grounds for disqualification from further consideration or termination of employment with DHS. Yes I understand that this consent is voluntary; however, I acknowledge that refusal to give this consent will remove me from further consideration for the position for I applied. Yes In addition to the Criminal History Background check, I give consent to the completion of a comprehensive background check including but not limited to education verification, Integrated Data System (IDS) and reference checks. Yes I also acknowledge that providing false information or failure to disclose any information pertaining to my identity or criminal history may be a violation of O.C.G.A §16-10-20 (False statements and writings, concealment of facts, and fraudulent documents in matters within jurisdiction of state or political subdivisions). Applicant’s Last, First, Middle Name Street Address or PO Box City, State, Zip Code Social Security Number Date of Birth City & State of Birth Gender Height Weight Eye Color College/University City & State Major Degree Graduation Date Full Name on Degree Signature of Applicant Date Name of DHS Organizational Unit Contact Person Number Email Address FOR USE ONLY: No criminal history found through GCIC system check. Criminal history found that prohibits hiring (See attached). Criminal history that does not prohibit hiring (See attached).
Consent%20for%20Release%20of%20Information.docx