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Furthermore, I understand my employment is conditional upon the School Corporation receiving a satisfactory report from its inquiries and the criminal history/child protection index check.  \nName: SS \\#  \n\n| Last, First, Middle Initial\u003Cbr>Address: |  |  |  |\n| --- | --- | --- | --- |\n| Street Address\u003Cbr>Email Address: | City | State | Zip |\n| Date of birth: | Phone: |  |  |\n\nmm/dd/yyyy  \nHas applicant ever used an alias, including different first, middle or last name or combination  \nof names in lifetime? Yes No  \nMaiden Name Other last name (specify previous marriage or other)  \nNickname Pre-adoptive name  \nPlease list all counties, citiies, and states of residence back to January 1, 1988 or your birthdate, whichever occurs first. Begin with the most current residence and work backwards.  \n\n| County/State | Begin Date | End Date | City and Explanation, if necessary |\n| --- | --- | --- | --- |\n| Example: Starke/IN | 5/1/2001 | Current | Knox, School address |\n| Example: Marshall/IN | 10/1/1995 | 5/1/2001 | Plymouth, Home address |\n|  |  |  |  |\n|  |  |  |  |\n|  |  |  |  |\n|  |  |  |  |\n|  |  |  |  |\n\nThe following information is required by the Department of Child Services for the Child Protection Index Check and isnot used as a condition of employment:  \nGender of Applicant at birth: Male Female  \nHas your gender changed? Yes No  \nRace of applicant:    \nSignature of applicant:  \nI certify that all the information I have provided on this authorization form is complete and accurate.  \nNote to Applicants: Please note you will receive an email from \"KidsTrack Support\" asking you to  \nlog on and approve your Expanded Child Protection Index Check. Your background check can not be completed without your authorization.","cbCainOS3mmrzm9h","https://ap.wps.com/l/cbCainOS3mmrzm9h","pdf",302803,"English","# Authorization and Scope\n## Applicant Identity and Contact Details\n## Alias, Maiden Name, and Nicknames\n## Prior Residence History\n## Child Protection Index Check Information\n## Certification and Signature","[{\"question\":\"What investigations does the applicant authorize for employment screening?\",\"answer\":\"The applicant authorizes investigations into personal background, previous employment, and related matters necessary for an employment decision, including an expanded national criminal history check and an expanded child protection index check.\"},{\"question\":\"Is employment dependent on the results of the background checks?\",\"answer\":\"Yes. Employment is conditional on the School Corporation receiving a satisfactory report from its inquiries and the criminal history/child protection index check.\"},{\"question\":\"What information is required for the child protection index check?\",\"answer\":\"The form requests the applicant’s gender at birth, whether their gender has changed, and the race of the applicant, along with signature certification and approval steps for the index check.\"}]","John Glenn School Corporation Employment Background Check - Authorization Form | PDF",1789633867]