Background Request Form How to submit your background check

Background Request Form How to submit your background check

Background Request Form
How to submit your background check request
1. If you have not yet created a Banner Learning Center (BLC) account, STOP!
You must create this account prior to sending in your background consent
forms. See Attachment A, see pages 18-20.
2. Please complete ALL fields on pages 2, 3, 4 and 5. If the information
requested does not apply, please indicate by marking “N/A” in the space
provided. Any blank spaces may cause delays in processing the background
check.
3. If you are a CURRENT resident of the state of New York, complete page 12.
4. If you have a CURRENT motor vehicle license in the state of Alaska,
complete page 16.
5. If you have a CURRENT motor vehicle license in the state of Washington,
complete page 17.
6. Fax ONLY pages 2, 3, 4 and 5. (Include pages 12, 16, or 17 if applicable).
7. A summary of your rights is provided for you in both English and Spanish,
see pages 6-11.
8. You will receive an email affirming Secure Hire’s receipt of your application
by 6:00PM daily.
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BACKGROUND CHECK COVER SHEET
COMPLETE ALL DOCUMEN TS AND SUBMIT VIA SE CURE FAX TO:
LOCAL FAX: 480.684.7249 OR 480.684.7250 * TOLL FREE FAX: 866.520.2474
NOTICE: TO AVOID DELAYS PLEASE COMPLETE ALL FIELDS
EMPLOYEE/STUDENT STATUS
 Is applicant a Banner
Employee?
 YES  NO
If YES, please indicate Lawson ID number ________
 Is applicant participating in
the Online Clinical Orientation
System (OCOS)?
 YES  NO
If YES, please indicate user name:_______________
If NO, please indicate Banner Learning Center (BLC)
user name: ________________________________
This section MUST be completed or the application will be rejected.
EMPLOYEE/STUDENT DEMOGRAPHIC INFORMATION
 APPLICANT NAME
SCHOOL NAME
(Last, First Middle Initial-please print)
(College, University, Institution, etc.)
 PLEASE IDENTIFY TYPE OF APPLICANT
PROGRAM TYPE
(Nursing, Pharmacy, etc)
 STUDENT
 FACULTY
 OTHER, If other, please identify:
_______________________________________________________
APPLICANT EMAIL ADDRESS
________________________________
APPLICANT PHONE NUMBER
( ______ ) _______ - ____________
BANNER FACILITY
FACULTY/ REP CONTACT NAME
_____________________________________________
FACULTY/REP PHONE NUMBER
( ______ ) _______ - ____________
DATE SUBMITTED
(e.g. Thunderbird, Northern Colorado, etc.)
__________________________________
_____/_______/_________
(MM/DD/YYYY)
NOTES/COMMENTS:
BANNER HEALTH SECURE HIRE
525 W BROWN RD SUITE 3318
MESA AZ 85201
866.922.2474
2
Facility ___________________ Position________________ Start Date Estimate___/___/______
DISCLOSURE AND AUTHORIZATION TO OBTAIN INVESTIGATIVE CONSUMER
REPORT FOR PERSONS SEEKING EDUCTIONAL AFFILIATION
As part of my application for educational placement with Banner Health, I understand that Banner Health
may obtain an Investigative Consumer Report ("Report"), which may include information as it pertains to
my character, general reputation, personal characteristics, mode of living and work habits. Such a Report
may be requested by Banner Health and/or its designated agents on behalf of Banner Health. These
Reports may include information relating to my past job performance and experience, including reasons
for termination, professional license and education verification, criminal and civil litigation history,
driving records and/or other reports. Further, I understand that information will be requested from various
federal, state, county or other agencies that maintain records. The scope of any subsequent consumer report
will contain the same elements identified in the pre-employment background check. The purpose of the
investigation will be to determine my continued suitability for patient contact or whether I possess the
minimum qualifications necessary for promotion, or transfer to another position. If I apply to become or
become a Banner Health employee the Report will also be used to evaluate me for employment,
promotion, reassignment or retention as an employee. The nature, scope and purpose of any subsequent
report will be the same as the nature, scope and purpose of a pre-employment report.
I understand that I will receive a copy of the “A Summary of Your Rights” provided by the federal
Fair Credit Reporting Act (FCRA). To obtain more information about my Report, I may contact
www.ftc.gov/credit or write to: Consumer Response Center, Room 130-A, Federal Trade
Commission, 600 Pennsylvania Ave. N.W., Washington, D.C. 20580.
THIS REPORT IS BEING OBTAINED BY:
BANNER HEALTH SECURE HIRE
525 W Brown Rd, Suite 3318
Mesa, AZ 85201
Toll Free 866-922-2474
*****NOTICE TO CALIFORNIA, OKLAHOMA, MINNESOTA, AND NEW YORK APPLICANTS*****
You have the right to obtain a copy of any Investigative Consumer Report obtained by Banner
Health by checking the box provided below. The Report will be provided to you within three (3)
business days after the Report is provided to Banner Health. Although the State Laws of CA, OK,
MN, and NY require this statement; any resident of any state may obtain a free copy of this Report
by marking the box below:
I request to receive a free copy of this Report by checking this box. 
_________Initial ___/___/_______Date
Consent Page 1 of 2
3
California Residents, please note that under section 1786.22 of the California Civil Code, you may
view the file maintained on you during normal business hours. You may also obtain a copy of the
file upon submitting proper identification and paying the costs of duplication services, if applicable,
you may also receive by mail or a summary of the file by telephone. Banner Health Secure Hire will
have personnel available to explain to you any coded information appearing in your file. If you
appear in person, a person of your choice may accompany you, provided that this person furnishes
proper identification.
New York Residents have the right to request the nature and substance of all information obtained
on your behalf by Banner Health Secure Hire, including the sources of information, as well as the
recipients of Background Reports within the two (2) year period preceding the request. New York
Residents are entitled to receive a copy of the New York Correction Law also known as Article 23-A
(attached) which pertains to the Licensure and Employment of Persons Previously Convicted of One
or More Criminal Offenses. To initiate such request, contact Henrietta Williams, Director of Banner
Health Secure Hire, at 525 W. Brown Road, Suite 3318, Mesa, AZ 85201, via email at
[email protected] or via toll free phone at 866-922-2474. I acknowledge that
Banner Health Secure Hire will request, and I must supply, proper identification should such request
be made.
This Disclosure and Authorization to Obtain Investigative Consumer Report, in original, faxed,
photocopied or electronic form will be valid for any Reports that may be requested by Banner
Health. I authorize Banner Health, Banner Health Secure Hire and/or its designated agents, without
reservation, permission to release all applicable records pertaining to the subject matter of this
Disclosure and Authorization to Obtain Investigative Consumer Report.
__________________________
Print Name
__________________
Social Security Number
__________________________
Signature
______________________
Signature Date: (MM/DD/YYYY)
__________________
Date of Birth: (MM/DD/YYYY)
Consent Page 2 of 2
4
BACKGROUND CHECK INFORMATION SHEET
APPLICANT INFORMATION
Full Name
Social Security Number
_________-______-___________
Names Used Please list all other names including maiden, alias, etc.
Driver’s License No. (Please Include State of Issue)
Address of Applicant (be sure to include street, city, state and zip code)
Contact Information
Street: ___________________________________________
Home Phone: (
) _____-__________
City: ___________________ State:_____ Zip Code: _______
Other Phone:
) _____-__________
(
Email: _________________________________
CRIMINAL HISTORY (Disclosure of previous convictions will not automatically disqualify you from consideration)
Have you ever been convicted of a crime? No Yes  If yes, please explain and include date(s), location and nature of offense
ADDRESS HISTORY (Please list all previous CITIES/STATES of residence, employment and education)
Address (example: Dallas, Texas)
Dates (example: from 01/01/2001 to 01/01/2011)
I authorize Banner Health, Banner Health Secure Hire and/or its designated agents to verify the information
set forth on this Background Check Information Sheet. I authorize the procurement of an investigative report
and understand that it may contain information pertaining to my past job performance and experience,
including reasons for termination, professional license and education verification, criminal and civil litigation
history, driving records and/or other reports.
I hereby certify this information to be true and correct to the best of my knowledge and belief.
Printed Name:
______________________________________________
Signature:
Date (MM/DD/YYYY)
______________________________________________
____/____/________
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Para informacion en espanol, visite www.ftc.gov/credit o escribe a la FTC Consumer Response Center,
Room 130-A 600 Pennsylvania Ave. N.W., Washington, D.C. 20580.
A Summary of Your Rights under the Fair Credit Reporting Act
The federal Fair Credit Reporting Act (FCRA) promotes the accuracy, fairness, and privacy of
information in the files of consumer reporting agencies. There are many types of consumer reporting
agencies, including credit bureaus and specialty agencies (such as agencies that sell information about
check writing histories, medical records, and rental history records). Here is a summary of your major
rights under the FCRA. For more information, including information about additional rights, go to
www.ftc.gov/credit or write to: Consumer Response Center, Room 130-A, Federal Trade Commission,
600 Pennsylvania Ave. N.W., Washington, D.C. 20580.
You must be told if information in your file has been used against you. Anyone who uses a
credit report or another type of consumer report to deny your application for credit,
insurance, or employment – or to take another adverse action against you – must tell you,
and must give you the name, address, and phone number of the agency that provided the
information.
You have the right to know what is in your file. You may request and obtain all the
information about you in the files of a consumer reporting agency (your “file disclosure”).
You will be required to provide proper identification, which may include your Social Security
number. In many cases, the disclosure will be free. You are entitled to a free file disclosure
if:
 a person has taken adverse action against you because of information in your
credit report;
 you are the victim of identity theft and place a fraud alert in your file;
 your file contains inaccurate information as a result of fraud;
 you are on public assistance;
 you are unemployed but expect to apply for employment within 60 days.
In addition, by September 2005 all consumers will be entitled to one free disclosure every 12 months
upon request from each nationwide credit bureau and from nationwide specialty consumer reporting
agencies. See www.ftc.gov/credit for additional information.
You have the right to ask for a credit score. Credit scores are numerical summaries of your
credit-worthiness based on information from credit bureaus. You may request a credit score
from consumer reporting agencies that create scores or distribute scores used in residential
real property loans, but you will have to pay for it. In some mortgage transactions, you will
receive credit score information for free from the mortgage lender.
You have the right to dispute incomplete or inaccurate information. If you identify
information in your file that is incomplete or inaccurate, and report it to the consumer
reporting agency, the agency must investigate unless your dispute is frivolous. See
www.ftc.gov/credit for an explanation of dispute procedures.
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Consumer reporting agencies must correct or delete inaccurate, incomplete, or
unverifiable information. Inaccurate, incomplete or unverifiable information must be
removed or corrected, usually within 30 days. However, a consumer reporting agency may
continue to report information it has verified as accurate.
Consumer reporting agencies may not report outdated negative information. In most
cases, a consumer reporting agency may not report negative information that is more than
seven years old, or bankruptcies that are more than 10 years old.
Access to your file is limited. A consumer reporting agency may provide information about
you only to people with a valid need -- usually to consider an application with a creditor,
insurer, employer, landlord, or other business. The FCRA specifies those with a valid need
for access.
You must give your consent for reports to be provided to employers. A consumer reporting
agency may not give out information about you to your employer, or a potential employer,
without your written consent given to the employer. Written consent generally is not
required in the trucking industry. For more information, go to www.ftc.gov/credit.
You may limit “prescreened” offers of credit and insurance you get based on information
in your credit report. Unsolicited “prescreened” offers for credit and insurance must include
a toll-free phone number you can call if you choose to remove your name and address from
the lists these offers are based on. You may opt-out with the nationwide credit bureaus at 1888-5-OPTOUT (1-888-567-8688).
You may seek damages from violators. If a consumer reporting agency, or, in some cases, a
user of consumer reports or a furnisher of information to a consumer reporting agency
violates the FCRA, you may be able to sue in state or federal court.
Identity theft victims and active duty military personnel have additional rights. For more
information, visit www.ftc.gov/credit.
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States may enforce the FCRA, and many states have their own consumer reporting laws. In some
cases, you may have more rights under state law. For more information, contact your state or local
consumer protection agency or your state Attorney General. Federal enforcers are:
TYPE OF BUSINESS:
Consumer Reporting Agencies,
creditors and others not listed below
CONTACT:
Federal Trade Commission:
Consumer Response Center - FCRA
Washington, DC 20580 1-877-382-4357
National banks, federal branches/agencies of foreign banks
(word "National" or initials "N.A." appear in or after bank's
name)
Office of the Comptroller of the Currency
Compliance Management, Mail Stop 6-6
Washington, DC 20219 800-613-6743
Federal Reserve System member banks (except national
banks, and federal branches/agencies of foreign banks)
Federal Reserve Consumer Help (FRCH)
P O Box 1200
Minneapolis, MN 55480
Telephone: 888-851-1920
Website Address: www.federalreserveconsumerhelp.gov
Email Address: [email protected]
Savings associations and federally chartered savings banks
(word "Federal" or initials "F.S.B." appear in federal
institution's name)
Office of Thrift Supervision
Consumer Complaints
Washington, DC 20552 800-842-6929
Federal credit unions (words "Federal Credit Union" appear in
institution's name)
National Credit Union Administration
1775 Duke Street
Alexandria, VA 22314 703-519-4600
State-chartered banks that are not members of the Federal
Reserve System
Federal Deposit Insurance Corporation
Consumer Response Center, 2345 Grand Avenue, Suite 100
Kansas City, Missouri 64108-2638 1-877-275-3342
Air, surface, or rail common carriers regulated by former Civil
Aeronautics Board or Interstate Commerce Commission
Department of Transportation,
Office of Financial Management
Washington, DC 20590
202-366-1306
Activities subject to the Packers and
Stockyards Act, 1921
Department of Agriculture
Office of Deputy Administrator - GIPSA
Washington, DC 20250 202-720-7051
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Un Resumen de Sus Derechos en Virtud de la Ley de Informe Justo de Crédito
La Ley Federal de Informe Justo de Crédito (Fair Credit Reporting Act, FCRA) fomenta la exactitud,
justicia y privacidad de la información en los expedientes de las agencias de informe del consumidor.
Existen muchos tipos de agencias de informe del consumidor, incluyendo las agencias de crédito (credit
bureaus) y las especializadas (como agencias que venden información sobre historial de firma de
cheques, expedientes médicos e historial de alquiler). A continuación tiene un breve resumen de sus
principales derechos en virtud de la FCRA. Para más
información, incluyendo información sobre derechos adicionales, visite
www.ftc.gov/credit/espanol_loans.htm o escriba a: Consumer Response Center, Room 130A, Federal Trade Commission, 600 Pennsylvania Ave. N.W., Washington, D.C. 20580.
Deben notificarle si la información en su expediente se ha utilizado en contra de
usted. Todo aquel que utilice un informe de crédito u otro tipo de informe de consumidor para
denegar su solicitud de crédito, seguro o empleo, o para emprender otra acción contra usted,
debe informarle y debe darle el nombre, la dirección y el teléfono de la agencia que
proporcionó esa información.
Tiene derecho a saber lo que está en su expediente. Puede solicitar y obtener toda la
información sobre usted en los archivos de una agencia de informe del consumidor. Deberá
proporcionar identificación, que puede incluir su número de Seguro Social. En muchos casos, la
divulgación de esta información será gratuita. Tiene derecho a una divulgación gratuita si:
 una persona ha emprendido una acción adversa contra usted debido a
información en su informe de crédito;
 usted es víctima de un robo de identidad y se coloca una alerta de fraude en su
expediente;
 su expediente contiene información no exacta como resultado de fraude;
 usted recibe asistencia pública;
 no está empleado pero anticipa solicitar empleo en 60 días.
Asimismo, para septiembre de 2005, todos los consumidores tendrán derecho a una divulgación cada 12
meses si así lo solicitan a cada agencia de crédito nacional y de las agencias nacionales de informe del
consumidor especializadas. Para información adicional, visite www.ftc.gov/credit/espanol_loans.htm.
Tiene derecho a pedir su puntuación de crédito. Las puntuaciones de crédito son resúmenes
numéricos de su valía de crédito basados en información de las agencias de crédito. Puede
solicitar una puntuación de crédito de agencias de informe del consumidor que crean
puntuaciones o distribuyen las puntuaciones utilizadas en préstamos de bienes raíces
residenciales, pero tendrá que pagar para recibirla. En algunas transacciones hipotecarias, el
prestamista le dará gratuitamente información sobre su puntuación de crédito.
9
Tiene derecho a confrontar información incompleta o no exacta. Si identifica información en
su expediente que es incompleta o inexacta, y la reporta a la agencia de informe del
consumidor, la agencia debe investigar a menos que su confrontación sea frívola. Visite
www.ftc.gov/credit/espanol_loans.htm para una explicación de los procedimientos de
confrontación.
Las agencias de informe del consumidor deben corregir o eliminar información inexacta,
incompleta o no verificable. La información no exacta, incompleta o no verificable debe ser
retirada o corregida, generalmente dentro de 30 días. No obstante, una agencia de informe del
consumidor puede seguir reportando información si ha verificado su exactitud.
Las agencias de informe del consumidor no pueden reportar información negativa atrasada.
En la mayoría de los casos, una agencia de informe del consumidor puede no reportar
información negativa ocurrida hace más de siete años, ni quiebras ocurridas hace más de 10
años.
El acceso a su expediente es limitado. Una agencia de informe del consumidor puede
proporcionar información sobre usted solamente a personas que realmente la necesiten
generalmente para considerar una solicitud con un acreedor, asegurador, empleador,
propietario de vivienda u otro negocio. La FCRA especifica quiénes son las personas que tienen
una necesidad válida de acceso.
Debe otorgar su consentimiento para que se envíen sus informes a empleadores. Una agencia
de informe del consumidor no puede dar información sobre usted a su empleador, o a un
posible empleador, sin su consentimiento escrito previo otorgado al empleador. El
consentimiento escrito generalmente no es requerido en la industria de camiones. Para más
información visite www.ftc.gov/credit/espanol_loans.htm.
Puede limitar las ofertas “preevaluadas” de crédito y seguro que obtiene basadas en
información en su informe de crédito. Las ofertas “preevaluadas” de crédito y seguro deben
incluir un número de teléfono sin cargo al que puede llamar si desea eliminar su nombre y
dirección de las listas en las que se basan estas ofertas. Puede optar por no figurar en las listas
de las agencias de crédito llamando al 1-888-5-OPTOUT (1-888-567-8888).
Puede obtener compensación de los acreedores. Si una agencia de informe del consumidor, o
en algunos casos, un usuario de informes de consumidor o proveedor de información a una
agencia de informe del consumidor infringe la FCRA, usted puede presentar un pleito en un
tribunal estatal o federal.
Las víctimas de robo de identidad y el personal militar en activo tienen derechos adicionales.
Para más información, visite www.ftc.gov/credit/espanol_loans.htm.
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Los estados tienen autoridad para hacer cumplir la FCRA, y muchos estados tienen su propia
legislación de informe del consumidor. En algunos casos, usted puede tener más derechos en
virtud de la ley estatal. Comuníquese con su agencia de protección estatal o local del consumidor
o su Fiscal general estatal. Las agencias a nivel federal son:
TIPO DE NEGOCIO:
Agencias de informe del consumidor, acreedores y
otros no mencionados abajo
CONTACTAR:
Federal Trade Commission:
Consumer Response Center - FCRA
Washington, DC 20580 1-877-382-4357
Bancos nacionales, sucursales/agencias federales de
bancos extranjeros (con la palabra “National” o las
iniciales “N.A.” en o después del nombre del banco)
Office of the Comptroller of the Currency
Compliance Management, Mail Stop 6-6
Washington, DC 20219 800-613-6743
Bancos que pertenecen al Sistema de la Reserva
Federal (salvo bancos nacionales, y
sucursales/agencias federales de bancos
extranjeros)
Federal Reserve Consumer Help (FRCH)
P O Box 1200
Minneapolis, MN 55480
Telephone: 888-851-1920
Website Address: www.federalreserveconsumerhelp.gov
Email Address: [email protected]
Asociaciones de ahorros y cajas de ahorros con
acreditación federal (con la palabra “Federal” o las
iniciales “F.S.B.” en el nombre de la institución
federal)
Bancos de crédito federales (con las palabras
“Federal Credit Union” en el nombre de la
institución)
Office of Thrift Supervision
Consumer Complaints
Washington, DC 20552 800-842-6929
National Credit Union Administration
1775 Duke Street
Alexandria, VA 22314 703-519-4600
Bancos acreditados a nivel estatal que no son
miembros del Sistema de la Reserva Federal
Federal Deposit Insurance Corporation
Consumer Response Center, 2345 Grand Avenue, Suite 100
Kansas City, Missouri 64108-2638 1-877-275-3342
Transportadores por aire, superficie o ferrocarril
regulados por la antigua Junta de Aeronáutica Civil
o por la Comisión Interestatal de Comercio
Department of Transportation,
Office of Financial Management
Washington, DC 20590
202-366-1306
Actividades sujetas a la Ley de Empacadores y
Estibadores de 1921
Department of Agriculture
Office of Deputy Administrator - GIPSA
Washington, DC 20250 202-720-7051
11
NEW YORK DISCLOSURE AND RELEASE
Current NY Residents Only
In connection with (1) my application for medical staff privileges or allied health professional staff privileges,
as the case may be, at any Banner Health facility, if I am seeking such privileges, (2) my application for
employment (including contract for services) with Banner Health (including any affiliate of Banner Health), if
I am seeking such employment, and/or (3) my request for recruitment assistance from a Banner Health
facility, if I am seeking such assistance, I understand that consumer reports that may contain public record
and investigative consumer information may be requested from Banner Health Secure Hire, 525 W. Brown
Road, Suite 3318, Mesa, AZ 85201. Background screening reports may include: Employment verification
(such as names of current and previous employers and dates of previous employment, reason for
termination of employment, work experience, etc). I further understand that such reports may contain
information concerning any criminal or civil records, educational achievements, professional license
verification, driving record, credit report from federal, state and other agencies which maintain such
records. I hereby consent to Banner Health Secure Hire obtaining the above information from such agencies.
I AUTHORIZE, WITHOUT RESERVATION, ANY PARTY OR AGENCY CONTACTED BY BANNER HEALTH SECURE
HIRE TO FURNISH THE ABOVE-MENTIONED INFORMATION.
I have the right to request the nature and substance of all information obtained on my behalf by Banner
Health Secure Hire including the sources of information; as well as the recipients of any reports on me the
agency has previously furnished within the two (2) year period preceding my request. I understand that to
initiate such request, I must contact Henrietta Williams, Director of Banner Health Secure Hire, at 525 W.
Brown Road, Suite 3318, Mesa, AZ 85201 or via email at [email protected] or via toll
free phone at 866-922-2474. I acknowledge that Banner Health Secure Hire will request and I must supply
proper identification should such request be made.
I hereby authorize procurement of consumer report(s). If I am granted medical staff privileges or allied
health professional staff privileges, as the case may be, at any Banner Health facility, if I become employed
by Banner Health (including any affiliate of Banner Health), or if I am receiving recruitment assistance from a
Banner Health facility, this authorization shall remain on file and shall serve as ongoing authorization for you
to procure consumer reports and investigative consumer reports at any time during the period that I have
staff privileges at any Banner Health Facility, that I am employed by Banner Health (including any affiliate of
Banner Health), or that I am receiving recruitment assistance from a Banner Health facility.
 I acknowledge receipt of a copy of Article 23-A of New York Correction Law.
(The following information is requested for use in performing a background check on you and for no other purpose.)
Print Name
Social Security No.
__________________________
Date of Birth
Applicant’s Signature
Date
12
-FOR CURRENT NY RESIDENTS ONLYNEW YORK CORRECTION LAW
ARTICLE 23-A
http://www.labor.ny.gov/agencyinfo/PDFs/CorrectionLaw%20Article%2023-A%20_4_.pdf
A COPY OF THIS LAW IS BEING PROVIDED TO YOU IN CONJUNCTION WITH
BANNER HEALTH INITIIATING A BACKGROUND SCREEN
LICENSURE AND EMPLOYMENT OF PERSONS PREVIOUSLY
CONVICTED OF ONE OR MORE CRIMINAL OFFENSES
New York Bus Code §380-c (b) (2) and 380-g (d)
Section 750. Definitions.
For the purposes of this article, the following terms have the following meanings:
1) “Public agency” means the state or any local subdivision thereof, or any state or local
department, agency, board or commission.
(2) “Private employer” means any person, company, corporation, labor organization or
association which employs ten or more persons.
(3) “Direct relationship” means that the nature of criminal conduct for which the person was
convicted has a direct bearing on his fitness or ability to perform one or more of the duties or
responsibilities necessarily related to the license, opportunity, or job in question.
(4) “License” means any certificate, license, permit or grant of permission required by the laws
of this state, its political subdivisions or instrumentalities as a condition for the lawful practice of
any occupation, employment, trade, vocation, business, or profession. Provided, however, that
“license” shall not, for the purposes of this article, include any license or permit to own, possess,
carry, or fire any explosive, pistol, handgun, rifle, shotgun, or other firearm.
(5) “Employment” means any occupation, vocation or employment, or any form of vocational or
educational training. Provided, however, that ‘employment” shall not, for the purposes of this
article, include membership in any law enforcement agency.
13
751. Applicability.
The provisions of this article shall apply to any application by any person for a license or employment at
any public or private employer, who has previously been convicted of one or more criminal offenses in
this state or in any other jurisdiction, and to any license or employment held by any person whose
conviction of one or more criminal offenses in this state or in any other jurisdiction preceded such
employment or granting of a license, except where a mandatory forfeiture, disability or bar to
employment is imposed by law, and has not been removed by an executive pardon, certificate of relief
from disabilities or certificate of good conduct. Nothing in this article shall be construed to affect any
right an employer may have with respect to an intentional misrepresentation in connection with an
application for employment made by a prospective employee or previously made by a current
employee.
§752. Unfair discrimination against persons previously convicted of one or more criminal offenses
prohibited. No application for any license or employment, and no employment or license held by an
individual, to which the provisions of this article are applicable, shall be denied or acted upon adversely
by reason of the individuals having been previously convicted of one or more criminal offenses, or by
reason of a finding of lack of ‘good moral character’ when such finding is based upon the fact that the
individual has previously been convicted of one or more criminal offenses, unless:
(1) There is a direct relationship between one or more of the previous criminal offenses and the
specific license or employment sought or held by the individual; or
(2) the issuance or continuation of the license or the granting or continuation of the employment
would involve an unreasonable risk to property or to the safety or welfare of specific individuals
or the general public.
§753. Factors to be considered concerning a previous criminal conviction; presumption.
1. In making a determination pursuant to section seven hundred fifty—two of this chapter, the public
agency or private employer shall consider the following factors:
(a) The public policy of this state, as expressed in this act, to encourage the licensure and
employment of persons previously convicted of one or more criminal offenses.
(b) The specific duties and responsibilities necessarily related to the license or employment
sought or held by the person.
(c) The bearing, if any, the criminal offense or offenses for which the person was previously
convicted will have on his fitness or ability to perform one or more such duties or
responsibilities.
(d) The time which has elapsed since the occurrence of the criminal offense or offenses.
(e) The age of the person at the time of occurrence of the criminal offense or offenses.
(f) The seriousness of the offense or offenses.
(g) Any information produced by the person, or produced on his behalf, in regard to his
rehabilitation and good conduct.
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(h) The legitimate interest of the public agency or private employer in protecting property, and
the safety and welfare of specific individuals or the general public.
2. In making a determination pursuant to section seven hundred fifty—two of this chapter, the public
agency or private employer shall also give consideration to a certificate of relief from disabilities or a
certificate of good conduct issued to the applicant, which certificate shall create a presumption of
rehabilitation in regard to the offense or offenses specified therein.
§754. Written statement upon denial of license or employment. At the request of any person
previously convicted of one or more criminal offenses who has been denied a license or employment, a
public agency or private employer shall provide, within thirty days of a request, a written statement
setting forth the reasons for such denial.
§755. Enforcement.
1. In relation to actions by public agencies, the provisions of this article shall be enforceable by a
proceeding brought pursuant to article seventy—eight of the civil practice law and rules.
2. In relation to actions by private employers, the provisions of this article shall be enforceable by
the division of human rights pursuant to the powers and procedures set forth in article fifteen of
the executive law, and, concurrently, by the New York city commission on human rights.
15
STATE OF ALASKA
REQUEST FOR DRIVING RECORD
Driving records are valid for 30 days.
I am requesting the following:
_____Driving Record (5 year / Insurance)
__X_ Driving Record (Full)
I would like the record to be mailed or (faxed) to the address or fax number shown below.
Your name, as shown on your Alaska license________________________________________________
Your signature ________________________________________________________________________
Telephone ___(_______)_______________________________Fax(_480) -684-7250_________
Mailing address _______________________________________________________________________
________________________________________________________________________
_______________________________
___/___/___
_____________________
ALASKA Driver License Number OR Date of Birth AND Social Security Number
Purpose of record: PRE EMPLOYMENT/PRE PLACEMENT
Please complete the following when requesting information via fax. If your request is made by mail,
include a check or money order payable to State of Alaska or DMV*.
(*COMPLETE INFORMATION ABOVE THIS BOX ONLY*)
MasterCard or Visa #_____________________________________ Expiration Date___/___/___
Visa Security Code (3-digit number on back of card)________________________
Name as shown on card_______________________________________________
I understand that my credit card shown above will be charged $10.00 for each driving record
requested.
Signature _______________________________________________________Date ___/___/___
(Signature of credit card holder.)
FAX: 1-907- MAIL: Division of Motor Vehicles
BATCH
Form 419F Rev. 01/01/2011
AMVC ID
(Valid for 90 days)
ATTN: RESEARCH
1300 W. Benson Boulevard, Suite 200
Anchorage AK 99503-3600
DMV USE ONLY
$10
OFFICE
FEE: CA
CC
CK
www.Alaska.gov/dmv
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Washington State Department of
Licensing
Driving Record Request
FOR VALIDATION ONLY
You may use this form to request your driving record. We will mail, email, or fax your record to
you or to the individual or company you request below. Mail this request and $10 for each
record in a check or money order payable to the Department of Licensing to:
106-060-421-0005
Driver Records
Department of Licensing
PO Box 9048
Olympia, WA 98507-9048
Please allow two weeks for processing. If you have additional questions, contact customer service at (360) 902-3900.
Requestor name (Last, First, Middle Initial)
Washington driver license number
Date of birth
(Area code) Daytime telephone number
Name of individual or company you want your drive record sent to:
Banner Health Secure Hire, Banner, Health Risk Management,
525 W Brown Rd, Suite 3318, Mesa AZ, 85201; Phone (480) 684-7236
How would you like your driving record sent to you? (Check one only)
U.S. mail
email
Fax
[email protected]
Delivery information (Mailing address, email, or [Area code] Fax number)
Type(s) of record
Insurance records will show violations, convictions, and accidents only. Other drive records will show all traffic-related
convictions, violations, collisions, suspensions, revocations, and disqualifications.
We offer the following types of driving records. Check the box beside the type(s) you need.
Noncommercial insurance record (3 year)–Used to create and renew vehicle insurance policies.
Commercial insurance record (3 year)– Used to create and renew commercial vehicle insurance policies.
Life insurance record (3 year)– Used to create and renew life insurance policies.
Employment record –Used by employers to determine employment eligibility.
Volunteer/ Transit record –Used to determine if a volunteer driver meets the insurance and risk-managment
requirements to drive a vanpool vehicle or should be permitted to operate a vehicle used to transport individuals who
are under 18, over 65, or disabled.
School bus driver record –Used to determine if a person should be employed to operate a school bus. This request is
to be billed and mailed to school district_________________________________________________
School district authorization ________________________ Requestor code _______________________________
Complete record – A complete driving record requested by the person named on the driving record.
I declare under penalty of perjury under the laws of the state of Washington that I am the individual named above.
________________________________ X_______________________________________________
Date and Place
Signature (valid for four months)
DR-500-009 (R/1/10)W
The Department of Licensing has a policy of providing equal access to its services.
If you need special accommodation, please call (360) 902-3900 or TTY (360) 664-0116.
17
-ATTACHMENT AHow to create your Banner Learning Center profile:
NOTE: If you have created a student/instructor Banner Learning Center account in the past and
cannot remember your login or password, DO NOT create another profile/account. E-mail
[email protected] or contact the Help Desk at 602-747-4444 (in Arizona) and 800-424-8930
(outside of Arizona) if you have any questions or concerns about your Banner Learning Center
account.
STEP 1. From any computer that has internet access type in: www.bannerhealth.com.
Enter the phrase [Banner learning center] in the Keyword box in upper right screen:
STEP 2. Create a new account Select “Students/Instructors” select the [Click Here] link.
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STEP 3. Complete information requested on the New User screen.
YOU MUST complete all RED areas with an Asterisks * as shown above.
Note: Additional Field Specific Instructions:
Field
A Employment
B Personal
Contact
Information
C Division:
D Position:
E Hire Date:
F Social Security
Number (SSN)
G School:
H Username:
I
Password:
Action
Select Non Employee.
Type in your most frequently used email address, contact phone number,
address, city, state and zip code.
Select Students and Interns Division, Corp.
Select on the appropriate student or instructor position.
Enter the date you are creating this profile.
You may enter 999-99-9999 if you wish instead of your SSN
Select on your school, select “other” if your school is not listed.
Enter Username in the following format: first initial of first name + last
name. Example: jdoe. The system will prompt you to add a number to the
end if there is a duplicate.
Create your own with a minimum of 6 alphanumeric characters.
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STEP 4. Lastly, when you are completed, select on
in the upper right hand corner.
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