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AUTHORIZATION
AND RELEASE FOR BACKGROUND CHECK
In connection with my
application for employment with Douglas County (“County”), I
understand that the County will conduct a check of my
background (“background check”) which may include obtaining
copies of personnel files or other records or documents,
credit information, information about criminal
convictions, driving records, civil court records,
educational transcripts and degrees, information about
positions held, dates of employment, last rate of pay, work
performance, disciplinary and attendance records,
reliability, any instances of dishonesty, insubordination,
threatening or intimidating behavior, unsafe or unlawful
conduct and any other information County may need to verify
information about my background, the accuracy of information
submitted by me during the application process and/or my
suitability for employment with County.
I authorize County and its
authorized employees or agents to investigate my background
and to investigate the accuracy and truthfulness of all
information submitted by me during the application process.
I authorize all persons involved in the hiring process to
discuss and review the results of any information or
documents obtained during any such investigation. I further
authorize all persons, businesses, current and former
employers and supervisors, educational institutions, law
enforcement agencies, motor vehicle departments, courts,
personal references, and/or other persons or entities
contacted by County to release to County any and all
information or records they may have concerning me, my
background and/or my suitability for employment with County.
This Authorization and Release does not apply to criminal
records expunged pursuant to ORS 419.262.
By signing below, I release
and hold harmless each person, employer, agency, business
and organization or other entity who or which provides
information or records to County pursuant to this
Authorization and Release from and against any and all
claims, liability or damages related to providing or
releasing information to County. I further release and hold
harmless Douglas County and each of its elected officials,
officers, employees and agents from and against any and all
claims, liability or damages related to any use or
disclosure by County of any information or records obtained
by reason of the background check conducted by County for
purposes related to consideration of my application for
employment and/or my employment with County.
A photocopy or facsimile of
this Authorization and Release shall be considered valid as
though it were an original and may be relied on to provide
or release information or records to County.
I have carefully read and
understand this Authorization and Release and voluntarily
agree to its terms to assist County in conducting a thorough
check of my background for purposes related to consideration
of my application for employment with County and/or, if
hired, my employment with County. I further understand that
all information and documents acquired by County in
conducting its background check will be maintained as
confidential by the County and will not be released by the
County to me or to others except as may be required under
the Fair Credit Reporting Act (“FCRA”), if applicable, or
other applicable laws.
______________________________
_______________ __________________________________
SIGNATURE OF APPLICANT DATE
SIGNATURE OF
WITNESS
*****************************************************PLEASE
PRINT LEGIBLY
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POSITION APPLIED FOR:
_______________________________________________
FULL NAME (Include all names
used - past or present) TELEPHONE
NUMBER
___________________________________
_________________
___________________________________
DATE OF
BIRTH SOCIAL SECURITY DRIVER’S
LICENSE or ID # STATE
________________ ___________________
______________________ ______
HOME ADDRESS:
______________________________________________________________________________
Douglas
County is authorized to conduct a background check on job
applicants pursuant to Douglas County policy and pursuant to
Oregon and Federal
law. Providing your social security number, date of birth
and driver’s license number are necessary to perform the
background check and will only be used with your consent for
the purposes described in this Authorization and Release.
Date of birth information will not be used as a basis for
making any hiring or other employment decision. |
