City of Raleigh
Investigative Background Check
This form is used by the Parks and Recreation Department to obtain background checks. The information provided on this form will be held in the strictest confidence. Please fully complete all sections in LEGIBLE PRINT so that your paperwork can be processed in a timely manner
PLEASE NOTE: You
must provide your FULLY NAME (first, middle, last, and maiden)
Name________________________________________________________________________________________________________________
Last First Middle Maiden/Nickname
Driver’s
License Number
______________________________________________________________ Issuing State _____________________
Date
of Birth ____________________________________________________________ Sex: Male/Female Race:________________
Month
Day Year
Social
Security Number ___________________________________________
Current
Address:_______________________________________________________________________________________________________
Street or RFD City County State Zip
Length
of Time at this Residence:________________
Years
Previous
Address
_____________________________________________________________________________________________________
Street or RFD City County State Zip
Length
of Time at this Residence:________________
Years
PLEASE NOTE: If the number of years that you have lived at your current address plus the number of years that you li8ved at your previous address is LESS THAN 3 YEARS, you must provide additional address(es) to equal three years.
Previous
Address
______________________________________________________________________________________________________
Street or RFD City County State Zip
Length
of Time at this Residence:________________
Years
Have you ever been convicted
of an offense against the Law? Yes No
(circle one)
Are you currently under
charges for any offense against the Law? Yes No (circle one)
If you answered
“Yes” to any of the above questions, please explain the circumstances:
___________________________________________________________________________________________________________
AUTHORIZATION OF A BACKGROUND
CHECK:
I hearby certify, by my signature below, that the information I have provided is accurate and true to the best of my knowledge and I authorize the City of Raleigh to conduct a periodic police, court, and sex offender records check on my background while I am employed with the City of Raleigh. I understand that the disclosure of a record will not result in an automatic disqualification from employment, but will be considered in relation to the specific position for which I am applying. I also understand that the failure to complete this form or providing false information will result in disqualification of employment.
_______________________________________________________ _____________________________]
Applicant’s Signature Date
*******************TO
BE COMPLETED BY PARKS AND RECREATION
STAFF*********************************************
Supervisor’s
Name____________________________________________________ Supervisor’s Phone Number _____________________
Positon
Desired by Applicant ____________________________________________
Position
requires Driving City or Personal Vehicle Yes No Position Requires Handling City Funds Yes No
Program________________________________________________________________ Work Location ________________________________
************************************TO
BE COMPLETED BY BUSINESS OFFICE STAFF ***********************************
Background
check was completed on ____________________ by ___________________ and the
following was determined:
Arrest
Information Sex Offender Registry
No arrest record was found
Positive
The arrest information is
attached
Negative