Free background check form 27
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Cumberland County Schools
Disclosure/Authorization for
Criminal Background Check
INSTRUCTIONS: Please fill form out in its entirety. Incomplete forms will delay processing.
Current Legal
Last Name:

Current Legal
First Name:

Social Security Number:

Sex:
 Female

Current Legal
Middle Name:

Driver’s License #:

Maiden/
All other names:

Ethnic Group:

 Male

ASIAN (including Pacific Islander)
BLACK (non-Hispanic)
 HISPANIC
 INDIAN (including Alaskan Native)
 WHITE (non-Hispanic)

Date of Birth:
/

State:
/

Email Address:

Residency Information: List last ten years, beginning with most current (NO PO BOXES)
Dates
FROM
MM/YY

ADDRESS

TO
MM/YY

CITY

STATE

ZIP CODE

Position(s) Applied for: (include all position that you want to be considered for)

Are you a current Cumberland County Schools employee? YES
Have you previously applied? YES

NO

NO

My signature below authorizes Cumberland County Schools (CCS) to obtain information about me from a consumer reporting agency f