Employee Statement Criminal Release Form
I have read the section on criminal history checks and understand the purpose and procedures as stated. I agree to participate in the procedures and grant my permission for the results to be disclosed to the employer, Trinity Services. I understand the criminal history and Health Care Registry check will be completed as a condition of employment.
Trinity Services agree to use the information from the state criminal history check only to verify information on my application for employment or statements I have made in regard to my employment. Trinity Services further agrees that this information will not be released without my written permission unless Trinity Services are authorized by law to release this information. A decision of employment will be made in accordance with Trinity Services criminal policy and the information received from the state’s criminal history check in accordance with the Freedom of Information Act.
I hereby release my employer, its directors, officers, employees, agents, and contractors from all liability claims and damages whatsoever that I may have for administration of the state’s criminal history and Health Care Registry check.
I understand that investigative backgrounds inquires are to be made on me including consumer credit, criminal convictions, motor vehicle, and any other needed reports included for this company. I understand that the company will be requesting information from various state, federal, other agencies and other levels concerning my past activities relating to my driving, credit, criminal, and other experiences as well as claims involving me and insurance companies.
In conclusion, I have read the attachments that define good moral character and testify that I am of good moral character as required by the administrative rules (Public Act 116 of 1973, as amended and Public Act 218 of 1979, as amended). I have not been convicted of nor have any charges pending against me in the areas stated on the attachments. I understand this is a condition of my employment with Trinity Services.
I hereby consent and authorize Trinity Services to obtain any needed information to complete my personnel file. The information can be received in its original state, fax, or copied form.
Applicants will not be employed if any information from the above list exists for the applicant. Applicants will also be denied employment if the applicant has committed or pleaded guilty to any of the listed offenses, any other major offenses not listed, or if the applicant refuses to submit fingerprints for a criminal background check.
APPLICATION FOR EMPLOYMENT FOR
If yes, please provide:
If yes, please provide:
Skills, Experience, and Trainings
Graduate or Professional
References: Please provide the name, address, and telephone number of three references. (No relatives please)
PLEASE READ THE BELOW CERTIFICATION OF APPLICATION BEFORE SIGNING.
Certification of Application
I hereby certify that all statements made in this application are true. I understand that any misstatement, misrepresentation, or omission of fact may be cause for my application not to be considered; or if I have been employed, may be cause for my immediate dismissal. I expressly authorize this agency to contact and obtain information from all references, employees, licensing authorities, public agencies, and educational institutions and to otherwise verify the accuracy of all information provided by me in this application or job interview. I hereby waive any rights and claims I may have regarding this agency for seeking, gathering, and using such information process and all other persons, corporations, or organizations for furnishing such information about me. If I am hired, I understand that I am free to resign at any time, with or without cause and without prior notice, and the employer reserves the same right to terminate my employment at any time, with or without cause and without prior notice, except as may be required by law. This application does not constitute an agreement or contract for employment for any specified period or definite duration.