Character & Fitness Name: ID#: SSN: (please print) Answer each question by marking or “yes” “no”. YES NO Have you ever had a professional certificate, license, credential or any document issued to you for practice denied, suspended, revoked or voluntarily surrendered? Are you currently reviewed or investigated for purposes of such action as stated in #1 or is such action pending? Have you ever been dismissed, resigned, released or asked to resign/retire or discharged from a professional position or military service for immorality, incompetence, willful neglect of duty, misconduct or presenting false information toward obtain the position? Is any such action as stated in #3 pending? Have you ever been convicted of a felony or misdemeanor (other than a moving traffic violation), been found guilty or entered a plea of nolo contendere (no contest), even if adjudication was withheld, in Kentucky or any other state? If you have indicated to any questions above, please explain here: “YES” University of the Cumberlands reserves the right to require a criminal background check at any time. If a criminal background check is required, the cost will be the candidate’s responsibility. All Teacher Education candidates will be required to have a FBI criminal background check completed for enrollment in Student Teaching. By checking this box, I acknowledge that I am the individual who has reviewed and electronically signed this document and submitted it to the University of the Cumberlands. Signature: Date:
Character & Fitness Name: ID#: SSN: (please print) YES NO Have you ever had a professional certificate, license, credential or any document issued to you for practice denied, suspended, revoked or voluntarily surrendered? Are you currently reviewed or investigated for purposes of such action as stated in #1 or is such action pending? Have you ever been dismissed, resigned, released or asked to resign/retire or discharged from a professional position or military service for immorality, incompetence, willful neglect of duty, misconduct or presenting false information toward obtain the position? Is any such action as stated in #3 pending? Have you ever been convicted of a felony or misdemeanor (other than a moving traffic violation), been found guilty or entered a plea of nolo contendere (no contest), even if adjudication was withheld, in Kentucky or any other state? Answer each question by marking “yes” or “no”. If you have indicated “YES” to any questions above, please explain here: University of the Cumberlands reserves the right to require a criminal background check at any time. If a criminal background check is required, the cost will be the candidate’s responsibility. All Teacher Education candidates will be required to have a FBI criminal background check completed for enrollment in Student Teaching. By checking this box, I acknowledge that I am the individual who has reviewed and electronically signed this document and submitted it to the University of the Cumberlands. Signature: Date:
character.docx