Consent to perform criminal history/background check
in compliance with the FCRA (Fair Credit Reporting Act)
Last name:__________________First name:__________________Middle name/initial:_________
Maiden or other name(s) used in any and all other records of birth or records of residence
_______________________________________________________________________________
Address:___________________________________________________Apt or #_____________
City:____________________County:_________________State:__________Zip:_____________
Date of birth:___________Social security number:______________Gender:____Race:______
AS SHOWN ON THE ORIGINAL APPLICATION. TO BE SHOWN FOR CRIMINAL HISTORY ONLY
I, ___________________________, am an applicant for employment, volunteer position, or as a participant in the
SAFE Family Program of the Victim Assistance Centre, Inc. And have been advised that as a part of the application
process, the VAC conducts a criminal history background check. I do hereby consent to the company use of any
information provided during the application process in preforming that would adversely impact a decision to offer
employment/ volunteer. In addition, I have been informed that I will have a reasonable opportunity to clear up any
mistaken information reported within a reasonable time frame established within the sole discretion of the
company. Under the fair credit reporting act, I have been advised that upon request I will be provided the name,
address and telephone number of the reporting agency as well as the nature, substance and source of all
information.
The following are my responses to questions about my criminal history (if any).
1. Have you ever been convicted or plead guilty before a court for any federal, state or
municipal criminal offense? (exclude minor traffic misdemeanors) ______ Yes ______No
If yes, please provide details below.
State:_______________County:____________________Date of offense _______/______/______
Details of conviction:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
2.Have you ever received deferred adjudication or similar disposition for any federal, state
or municipal offense? _____ Y ______ N
If yes, please provide details below.
State:_______________County:___________________Date of offense ______/______/______
Details of conviction:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
3. Have you ever received probation or community supervision for any federal, state or
municipal offense? ______Y ______ N
State:__________________County:________________Date of offense: ______/______/______
Details of conviction:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
____________________________________ ____________________________
Applicant Signature Date