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APPLICANT INFORMATION |
INFORMATION RELEASE & ACKNOWLEDGEMENT |
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Social Security No. _______ -_______-________
First Name: _______________________________
Middle Name: ____________________________
Last Name: _______________________________
Suffix: ______________
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I certify that the information provided in the box to the left is true and complete. I understand that false or misleading information given in my employment application, interview(s), or on this form will render my application void and will be just cause for termination of my employment. I also authorize you to make a criminal background investigation and other such investigations as are necessary in arriving at an employment decision. I further authorize the Illinois State Police to release criminal background information to US Investigation Services, Inc. (USIS) as part of the criminal background investigation.
________________________________________ Applicant Signature Date |
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Date of Birth: ________/_________/_______ Month Day Year
Sex: _______ Race:________
Street Address:___________________________ |
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City: _______________ State:_______________ Zip Code: _____________ |
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If you may be known by another name, please indicate:
__________________, _____________________ Last Name First Name
___________ Middle Initial
**INFORMATION IN THIS BOX IS REQUIRED FOR A BACKGROUND CHECK IN THE STATE OF ILLINOIS BY THE UNIFORM CRIMINAL INFORMATION ACT.** |
IMPORTANT---PLEASE READ CAREFULLY BEFORE SIGNING ACKNOWLEDGEMENT!
University of Illinois at Chicago may, upon execution of this authorization, investigate the information contained in your employment application and/or other background information, the results of which will be used as a factor in making employment decisions. Thus, you may be the subject of “consumer reports” requested by the company from an outside agency. These reports may be obtained at any time after receipt of your authorization and throughout your employment. A “consumer report” may contain information obtained from an outside agency on your credit standing, credit capacity, character, general reputation, personal characteristics and mode of living which will be used to establish your eligibility. In the event that information from the report is used in whole or in part in making an adverse employment decision, before making the adverse decision, we will provide you with a copy of the consumer report and a description in writing of your rights under the Fair Credit Reporting Act. A financial consumer report is NOT run as a part of this check. Acknowledgement & Authorization
I acknowledge receipt of the above information and certify that I have read/understand this form. I also authorize the University of Illinois at Chicago to obtain a consumer report at any time after receipt of this authorization or during my employment.
____________________ _____-______-______ Print Name SSN
______________________________________________ Signature Date |
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DEPT/POSITION INFORMATION |
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For this employee please run: _____ Background Check and Sanction Check _____ Background Check only _____ Sanction Check only
Will this person be working in the Hospital or Clinics? Y / N
Department Name: _____________________________
Dept Contact: ________________________________
Phone # for contact: ___________________________
Employee UIN: _______________________________
Hire Date: ___________________________________
FOAPAL to be charged:
_____-_______-_________-____________ COA Fund Org Program |
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Title of Position Sought/Offered:
________________________________________ |
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PRINT AND MAIL THE COMPLETED RELEASE FORM TO
UIC Human Resources 715 S. Wood Street, Room 109 M/C 862 |
UIC HUMAN RESOURCES DEPARTMENT Revised 01/2006