ࡱ> ~%` 0bjbjNN 4,,DDDDDDDXX%88ppppp~l$!$!$!$!$!$!$$%h6(E$D.pp..E$DDpp$   .FDpDp$ .$  o DD p, ke;{tj C!$0% ( ( (D .. .....E$E$...%....XXXXXXXXXDDDDDD AUTHORIZATION FOR RELEASE OF INFORMATION If Approved, please submit a copy of this form with the appointment papers. (Please print all responses, and the account information must be completed at the bottom of the page before this form will be processed.) If any part of this form is left incomplete, the form will be returned to the hiring department. I, FORMTEXT      , applicant for employment with Southern Illinois University Edwardsville for the position of  FORMTEXT      , hereby authorize a review of and full disclosure of all employment, education, and criminal and credit history information concerning myself, including any conviction, to any duly authorized agent of Southern Illinois University Edwardsville. I understand that any information obtained by such background investigation, which is acquired as a result of this release authorization will be considered in determining my suitability for employment with Southern Illinois University at Edwardsville. I also certify that any person(s) who may furnish such information concerning me shall not be held accountable for giving this information; and I do hereby release said person(s) from any and all liability which may be incurred as a result of collecting and considering such information. A photocopy or facsimile of this release form will be valid as an original thereof; even though said copy does not contain an original writing of my signature. I have read and fully understand the contents of this "Authorization for Release of Information". You must answer the following questions and provide any information as requested: 1. HAVE YOU EVER USED ANOTHER NAME? >>>>>>>>>  FORMCHECKBOX  YES OR  FORMCHECKBOX  NO IF YES, LIST THE NAMES HERE OR ON AN ATTACHMENT. IN THE LAST TEN YEARS, HAVE YOU LIVED, WORKED, OR ATTENDED SCHOOL OUTSIDE OF THE FOLLOWING COUNTIES: St. Louis City, MO; St. Louis County, MO; Madison County, IL; St. Clair County, IL? >>>>>>>>>  FORMCHECKBOX  YES OR  FORMCHECKBOX  NO IF YES, LIST THE CITIES AND STATES, AS WELL AS THE APPROPRIATE DATES, HERE OR ON AN ATTACHMENT. NOTE: As part of the background information that you provide on this application, you are not required to provide, and you shall not voluntarily provide, SIUE with any information regarding any conviction/arrest records pertaining to you that have been sealed or expunged. A conviction record will not necessarily be a bar to employment; factors such as age at the time of the offense, seriousness and nature of the violation, and rehabilitation will be taken into account in terms of the position applied for. Misrepresentation or omission of facts in your response to any question will be cause for rejection of your application or termination of employment. HAVE YOU EVER BEEN CONVICTED OF A MISDEMEANOR, FELONY OR PLEADED NO CONTEST? >>>>>>>>>  FORMCHECKBOX  YES OR  FORMCHECKBOX  NO IF YES, IDENTIFY, ON AN ATTACHMENT, ALL CONVICTIONS BY PROVIDING AN EXPLANATION INCLUDING DATE, CITY, STATE, AND CHARGE. 4. HAVE YOU EVER BEEN PLACED ON COURT SUPERVISION? >>>>>>>>>  FORMCHECKBOX  YES OR  FORMCHECKBOX  NO IF YES, EXPLAIN INDICATING DATES, CITY, AND CHARGE PRINT NAME (First, Middle Initial, Last): FORMTEXT      ADDRESS: FORMTEXT      CITY, STATE, ZIP: FORMTEXT      TELEPHONE: FORMTEXT      SOC SEC NO.: FORMTEXT      Banner ID: FORMTEXT      BIRTH DATE: FORMTEXT      STATE DRIVER'S LICENSE NO.: FORMTEXT      STATE FORMTEXT   SIGNATURE:DATE: FORMTEXT      By my signature on this release of information, I acknowledge that Southern Illinois University Edwardsville did not inquire about any information regarding conviction/arrest records that have been sealed or expunged. To be completed by the hiring unit: Posting #: FORMTEXT      Type of Position:  FORMCHECKBOX  Faculty  FORMCHECKBOX  Admin/Professional Staff  FORMCHECKBOX  Civil Service  FORMCHECKBOX  Grad Asst  FORMCHECKBOX  Student AIS Budget Purpose/Acct Title to be charged: FORMTEXT      HIRING UNIT/CONTACT PERSON/CAMPUS BOX: FORMTEXT      Chancellor/VC: FORMCHECKBOX  Chancellor  FORMCHECKBOX  Academic Affrs  FORMCHECKBOX  Admin  FORMCHECKBOX  Student Affrs  FORMCHECKBOX  University RelationsTo be completed by HR:Approved for offer: FORMCHECKBOX  YES  FORMCHECKBOX  NOHR Representative Signature:Date: SIUE-Credit Report Authorization and Privacy Disclosure Form Southern Illinois University Edwardsville, employer, hereby provides written notice to the application/employee of its intent to request and review a consumer report/credit report from an outside agency as a part of its consideration and review of my application and suitability for employment at Southern Illinois University Edwardsville. In addition, if employed, I am hereby notified that prior to or at any time after my employment starts a consumer report/credit report may be requested for employment eligibility purposes. The employer, Southern Illinois University Edwardsville, will obtain its consumer report from VanElla Inc., or any Employment Screening Service Agency that the employer may choose. 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