Nycdoe Fingerprint Referral Form

The New York City Department of Education Division of Human Resources Talent 65 Court Street Brooklyn New York 11201 FINGERPRINT REFERRAL FORM GENERAL INSTRUCTIONS Please print all information clearly on the form. Section I Certification Referring Official must be completed by the appropriate office. Section II Background Questions must be completed by the applicant. Section III Employment Eligibility Verification will be completed by the Office of Personnel Investigation* OFFICE USE ONLY I-9 CODE PLACE OF BIRTH / HEIGHT ORG* CODE FEET INCHES Y R EXP. DATE // A HAIR COLOR EYE COLOR SECTION I BACKGROUND INVESTIGATION IN THE TITLE OF Signature of Referring Official Office/District Telephone Number TODAY S DATE SOCIAL SECURITY NUMBER - Month Day Year LAST NAME FIRST NAME OTHER OR MAIDEN NAME M. I. Male DATE OF BIRTH Female PLEASE ONE CHECK THE BOX BELOW WHICH BEST DESCRIBES YOU AMERICAN INDIAN/ALASKAN NATIVES BLACK Not of Hispanic Origin ASIAN INCLUDES ASIAN INDIANS CHINESE JAPANESE KOREANS FILIPINOS INDONESIANS AND POLYNESIANS HISPANIC WHITE Not of Hispanic Origin STREET ADDRESS APT. NUMBER CITY STATE AREA ZIP CODE TELEPHONE NUMBER E-MAIL ADDRESS FILE NUMBER IF ANY FORM 551 1096 Answer YES or NO to the following questions. If your answer to any of these questions is YES explain giving details in the space provided below. You must answer these questions truthfully even though you may have disclosed the same information to the Department of Education or another agency on a previous occasion* Please be advised that if you answer NO to question 1 and your fingerprint results disclose a conviction record your application will be denied* Please sign your name at the end of this section* YES Have you ever been convicted of or pled GUILTY or pled NO CONTEST to any offense in this state or elsewhere This includes Felonies Misdemeanors and Violations. For Felonies or Misdemeanors you must answer Yes if you were convicted or pled guilty or no contest even if your records have been sealed* Are any criminal charges currently pending against you anywhere Have you ever forfeited bail or bond following your appearance as a defendant in a criminal court action Has a warrant been issued by a court requiring that you appear in court 6a* Has a Family Court ever found that you abused or neglected a child If so explain below which court issued the finding the nature of the finding and when it happened* 6b. Are you currently in arrears 4 months or more for child support payments due to reduction in the work force investigation If so explain the reasons for denial of employment below. Have you ever resigned or left a job rather than face charges or dismissal 10a* Has an employer ever brought or filed charges against you 10b. If yes were you found guilty of the charges Have you ever had any professional certificate or license denied revoked or suspended Have you ever applied for a civil service position such as police officer or worker for a federal state city or local agency and been notified you do not qualify Department New York City New York State or elsewhere Have you ever lost your job as a teacher or as another pedagogue before achieving tenure Did you ever receive a discharge from military service for reasons other than an honorable discharge 17a* Are you now or were you ever employed by the NYC Department of Education If yes indicate dates.