NAME:DOB:(MM/DD/YYYY)

SOCIAL SECURITY NUMBER: (SSN may be filled in when submitted)
DRIVER’S LICENSE NUMBER:
PHONE:(555-555-5555)

DEPARTMENT/COMPANY:
MANAGER/SUPERVISOR NAME:
MANAGER/SUPERVISOR PHONE:(555-555-5555)

HOME ADDRESS:

HAVE YOU LIVED AT THIS ADDRESS LESS THAN 5 YEARS: 
 YESNO

(If yes, please list your previous address)

NAME, PHONE,. AND ADDRESS OF PERSON/COMPANY RECEIVING RESULTS NOTIFICATION:

REASON FOR CRIMINAL HISTORY CHECK:

***If you have ever been convicted explain in space provided.

   (NOTE:  A conviction may or may not result in confinement).  Include every conviction, including traffic offenses, but not parking citations. (NOTE:  A record of conviction is NOT an automatic bar to employment)  Please read and initial next to the below listed statement:

I UNDERSTAND THAT ANY INTENTIONAL OR UNINTENTIONAL MISREPRESENTATION OF FACT IN MY APPLICATION WILL BE CAUSE FOR DISMISSAL, CANCELLATION, OF OFFER, AND OR NEGOTIATION OF ANY ADDITIONAL EMPLOYMENT CONSIDERATION OR AGREEMENT.  I HEREBY AUTHORIZE THE UNIVERSITY OF CINCINNATI TO INVESTIGATE THESE STATEMENTS.  I ALSO AUTHORIZE ANY CITY, COUNTY, STATE OR FEDERAL LAW ENFORCEMENT AGENCY OR COURT RELATED THERETO TO RELEASE INFORMATION THEY POSESS CONCERNING ME OR ANY PRIOR ARREST WHICH RESULTS IN A CONVICTON. 

 Date of Conviction     City/State       Charge      Penalty Assessed

Please print this form and take it with you to Three Edwards.