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Page 1 of 4 DISCLOSURE AND CONSENT FORM FOR BACKGROUND INVESTIGATION Requirement to Disclose: If you answer “YES” to question 5E and/or 5F, you must complete Section 1and 4 and then 2 and/or 3as applicable. Ask for additional sheets if needed. SECTION 1 Last Name First Name Middle Position Applying for Address City State Zip Telephone Date of Birth Social Security Number Former Names/aliases/a.k.a SECTION 2: Removal from Employment Explanation Name of Employer: Address: Job Title: Dates of employment: Reason(s) for removal from employment: Further explanation: (attach additional pages if necessary) Name of Employer: Address: Job Title: Dates of employment: Reason(s) for removal from employment: Further explanation: (attach additional pages if necessary) Name of Employer: Address: Job Title: Dates of employment: Reason(s) for removal from employment: Further explanation: (attach additional pages if necessary) ---PAGE BREAK--- Page 2 of 4 DISCLOSURE AND CONSENT FORM FOR BACKGROUND INVESTIGATION SECTION 3: Conviction and/or Pending Charges Explanation Name of Crime: Type: ☐Misdemeanor ☐Felony Date of Crime: Name and Location of the Court: Adjudication: ☐ Guilty ☐ Not Guilty ☐ Dismissed Year Convicted (if not pending): Age at Time of Offense: Name Offense Committed Under (if different than current): Explain the circumstances of the offense: (attach additional pages if necessary) List all evidence that exists regarding your rehabilitation: (attach additional pages if necessary) Explain why your conviction(s) and/or pending charges will not affect your fitness to perform the duties and responsibilities related to the position applied for: (attach additional pages if necessary) Explain why your conviction(s) and/or pending charges will not be a hindrance to the County’s legitimate interest in protecting property, and the safety and welfare of specific individuals or the general public: (attach additional pages if necessary) Name of Crime: Type: ☐Misdemeanor ☐Felony Date of Crime: Name and Location of the Court: Adjudication: ☐ Guilty ☐ Not Guilty ☐ Dismissed Year Convicted (if not pending): Age at Time of Offense: Name Offense Committed Under (if different than current): Explain the circumstances of the offense: (attach additional pages if necessary) List all evidence that exists regarding your rehabilitation: (attach additional pages if necessary) Explain why your conviction(s) and/or pending charges will not affect your fitness to perform the duties and responsibilities related to the position applied for: (attach additional pages if necessary) Explain why your conviction(s) and/or pending charges will not be a hindrance to the County’s legitimate interest in protecting property, and the safety and welfare of specific individuals or the general public: (attach additional pages if necessary) Signature: Date: ---PAGE BREAK--- Page 3 of 4 DISCLOSURE AND CONSENT FORM FOR BACKGROUND INVESTIGATION Name of Crime: Type: ☐Misdemeanor ☐Felony Date of Crime: Name and Location of the Court: Adjudication: ☐ Guilty ☐ Not Guilty ☐ Dismissed Year Convicted (if not pending): Age at Time of Offense: Name Offense Committed Under (if different than current): Explain the circumstances of the offense: (attach additional pages if necessary) List all evidence that exists regarding your rehabilitation: (attach additional pages if necessary) Explain why your conviction(s) and/or pending charges will not affect your fitness to perform the duties and responsibilities related to the position applied for: (attach additional pages if necessary) Explain why your conviction(s) and/or pending charges will not be a hindrance to the County’s legitimate interest in protecting property, and the safety and welfare of specific individuals or the general public: (attach additional pages if necessary) Signature: Date: SECTION 4: Certification and Authorization to Access Additional Information By my signature below, I, certify that information I provided on this form and Print Name any attachments is true, correct and complete. I understand that providing false or incomplete information or withholding by omission or intention pertinent information may be cause for disqualification of my application for employment. I understand that the County of Cortland may contact other individuals to clarify and verify information supplied on this form. I acknowledge and consent to a State and national criminal background investigation, which will include a fingerprint check to determine suitability for employment. Failure to meet the standards of the background investigation may result in disqualification. I authorize law enforcement agencies, learning institutions (including public and private schools and universities), courts (federal, state and local), motor vehicle records agencies, my past and present employers, the military and other individuals and sources to furnish any and all information on me that is requested by the County of Cortland. I agree that this Authorization form in original, faxed, photocopied or electronic (including electronically signed) form will be valid for any reports that may be requested by or on behalf of the County of Cortland. I acknowledge that I have read, understood and agreed freely to the requirements, consents, and authorizations. Signature: Date: ---PAGE BREAK--- Page 4 of 4 ADDENDUM DISCLOSURE AND CONSENT FORM FOR BACKGROUND INVESTIGATION SECTION 3: Conviction and/or Pending Charges Explanation Name of Crime: Type: ☐Misdemeanor ☐Felony Date of Crime: Name and Location of the Court: Adjudication: ☐ Guilty ☐ Not Guilty ☐ Dismissed Year Convicted (if not pending): Age at Time of Offense: Name Offense Committed Under (if different than current): Explain the circumstances of the offense: (attach additional pages if necessary) List all evidence that exists regarding your rehabilitation: (attach additional pages if necessary) Explain why your conviction(s) and/or pending charges will not affect your fitness to perform the duties and responsibilities related to the position applied for: (attach additional pages if necessary) Explain why your conviction(s) and/or pending charges will not be a hindrance to the County’s legitimate interest in protecting property, and the safety and welfare of specific individuals or the general public: (attach additional pages if necessary) Name of Crime: Type: ☐Misdemeanor ☐Felony Date of Crime: Name and Location of the Court: Adjudication: ☐ Guilty ☐ Not Guilty ☐ Dismissed Year Convicted (if not pending): Age at Time of Offense: Name Offense Committed Under (if different than current): Explain the circumstances of the offense: (attach additional pages if necessary) List all evidence that exists regarding your rehabilitation: (attach additional pages if necessary) Explain why your conviction(s) and/or pending charges will not affect your fitness to perform the duties and responsibilities related to the position applied for: (attach additional pages if necessary) Explain why your conviction(s) and/or pending charges will not be a hindrance to the County’s legitimate interest in protecting property, and the safety and welfare of specific individuals or the general public: (attach additional pages if necessary) Signature: Date: REV 2020