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Background Check Request Form
To be completed by the Hiring Official or Designee

Hiring Official/Designee Information:
Name:

Department:

Phone:

e-Mail:

PurCard Holder:

PurCard Holder’s e-Mail:

PurCard Holder’s Phone:

Job Information:

Regular Position

Applicant’s Name, LAST:

Temporary Position

FIRST:

Advertising Title of the Position Being Filled:
Job Duties Substantiating Background Check Request (e.g., access to: buildings, confidential information, minors, money)

Applicant Forms To Be Completed and Attached:
Disclosure Notice

Acknowledgment and Authorization

Documents to be given to the applicant when completing the Disclosure Notice and the Acknowledgment and
Authorization Form:
Summary of Your Rights Under the Fair Credit Reporting Act (given to everyone)
California Summary of Rights (California residents only)
Article 23-A of the New York Correction Law (New York residents only)

Hiring Official/Designee Signature

[ HRS Use Only ]
Updated June 2017

Date

HRS Requ