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Background Check Order Form

Thank you for your interest in employment with the Colorado School of Mines. Please complete the following online consent form.
For technical assistance please contact 1-877-360-4636.

Required fields are marked as *  

Please use your full legal name to fill out the following application and background check consent form.

First Name:* Last Name:*
Middle Name: Current Street Address:*
City:* State:* Zip:*
Date of Birth:* Email: *
Do you have a Social Security Number?* Yes No
Select One of the Following:* Faculty/Staff Student

Have you been convicted of, entered a plea of "guilty" or "no contest", or received a deferred prosecution or judgment for any felony or misdemeanor? Note: It is not necessary to list misdemeanor traffic (infractions) citations; however, all alcohol and drug related offenses of any kind must be listed (including traffic related offenses involving alcohol or drugs). If "YES," please provide details, including the date, court in which the conviction was entered, type of misdemeanor or felony, etc.

IMPORTANT: Your failure to provide an answer to this question may cause the offer of employment/appointment to be withdrawn.

Please Answer "yes" or "no":* Yes No
If yes, please explain
Please list the department/department contact name who extended your job offer:*
Please list any maiden or AKA names you may have used:
If applicable, please provide your Campus Wide ID (CWID) number:
Have you lived outside of the US in the past 7 years? Yes No
Please provide your full international address here:
City :
Your National ID number (i.e. Brazil CPF, Mexico CURP, etc.) :
We need additional information if you lived in any of the following countries:
Have you lived in India? Yes No
Please provide your father's name:
Have you lived in China? Yes No
Please provide your Chinese ID number or passport number if you are not a Chinese citizen:
Have you lived in Latin America? Yes No
Please provide your mother's maiden name:

BACKGROUND INVESTIGATION DISCLOSURE AND AUTHORIZATION

In connection with my application for employment, continued employment, or volunteer appointment with Colorado School of Mines ("School"), I understand that the School may request Consumer Reports and/or Investigative Consumer Reports ("Reports") from a consumer reporting agency. The School will use any such Reports solely for employment-related and/or volunteer screening purposes. Info Cubic, LLC may provide me a copy of the Report(s) obtained through this investigation process if I request one in writing.

Reports will be obtained from Info Cubic, LLC, located at 9250 E. Costilla Ave, Suite 525, Greenwood Village, CO 80112 (or from other such agent as the School determines). Info Cubic, LLC can be contacted at 1-877-360-4636. Examples of the types of information contained in these Reports may include but are not limited to: social security number verification, criminal records checks, public court records checks, public agency records, educational records, credit reports, verification of employment positions held, personal and professional references, licensing, and certifications. Such information may be obtained by Info Cubic, LLC from private or public record sources, employers, educational institutions, organizations, and individuals.

I acknowledge that the School has provided me a copy of the "Summary of Your Rights Under the Fair Credit Reporting Act" prepared pursuant to 15 U.S.C. section 1681(g)(c). I understand that I have the right to request additional information about the nature and scope of the background investigation and resulting Reports by submitting a written request to the School at: Colorado School of Mines, Human Resources Office, 1500 Illinois Street, Golden, CO 80401. If I am a resident of California, Maine, or New York, I acknowledge that I have read the applicable state law disclosure information at the end of this form.

By my signature below, I expressly authorize the School and Info Cubic, LLC to perform a background investigation on me and release to the School the resulting Reports in conjunction with my application for employment and/or volunteer appointment. I further understand that any and all information contained in my application or otherwise disclosed to the School by me may be utilized for the purpose of obtaining the Reports requested by the School. I understand and agree that if the School offers me employment and/or volunteer appointment, it may request a consumer report and/or an investigative consumer report about me for employment-related and/or volunteer screening purposes during the course of my employment and/or volunteer appointment. I understand that my authorization for and consent to this background investigation will be valid for the duration of my employment and/or volunteer appointment with the School.

To facilitate the School's background investigation, I hereby authorize, request, and require any persons, government agencies, educational institutions, corporations, or any other public or private entity contacted by the School, Info Cubic, LLC or its agents to disclose and release to Info Cubic, LLC and the School any information and records they have regarding my employment history, educational records, credit history and standing, motor vehicle history and standing, and criminal history. I understand and agree that a facsimile (FAX) or photographic copy of this authorization will be as valid as the original.

I understand that any offer of employment and/volunteer appointment I may receive is contingent upon the successful completion of the School's background investigation. I further understand that any false or incomplete information provided on this form, in my employment and or volunteer application or supporting materials may be cause for rejection of my application or termination of employment and/or volunteer appointment.

I understand that to facilitate the proper identification of my file or records, my disclosure of the personal information requested below is necessary.

I understand that I may request a copy of the background check by contacting Info Cubic, LLC directly by phone at 1-877-360-4636 or by visiting http://www.infocubic.com/resources-for-you/ to view, complete and return compliance details and forms such as "Request a Copy of Consumer Report."

California, Maine and New York Residents Only - Additional State Law Notices:

California: Under section 1786.22 of the California Civil Code, you may view the file maintained on you by Info Cubic, LLC. You must contact Info Cubic, LLC directly by phone at 1-877-360-4636 or visit http://www.infocubic.com/resources-for-you/ to view, complete and return compliance details and forms such as "Request a Copy of Consumer Report". Info Cubic, LLC has trained personnel available to explain your file to you, including any coded information.

Maine: You have the right upon request, to be informed of whether an investigative consumer report was requested, and if one was requested, the name and address of the consumer reporting agency furnishing the report. You may request and receive from the University, within five business days of our receipt of your request, the name, address and telephone number of the nearest unit designated to handle inquiries for the consumer reporting agency issuing an investigative consumer report concerning you. You also have the right, under Maine law, to request and promptly receive from all such consumer reporting agencies copies of any such investigative consumer reports.

New York: You have the right, upon written request, to be informed of whether or not a consumer report was requested. If a consumer report is requested, you will be provided with the name and address of the consumer reporting agency furnishing the report.

This document is not an offer of employment.

Enter Name as Signature:* Dated: *


I consent to pre-employment screening, including verifying education and professional credentials, past employment, and court records. This consent is valid for future screening for retention, promotion, or reassignment.



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