SECTION 5
1.I have read "Fingerprinting Information and Instructions" (OSPRA 100) issued by the State Education Department and understand that the Commissioner of Education is required by law and regulation to request a fingerprint-supported criminal history record from the Division of Criminal Justice Services (DCJS) and the Federal Bureau of Investigation (FBI). The Commissioner is authorized to review such information for the purposes of issuing a clearance for employment or the certificate for which I have applied.
2.I have been informed of the procedures and my right to obtain, review, and challenge the accuracy and completeness, where appropriate, of my criminal history information pursuant to regulations and procedures established by DCJS and the FBI.
3.I understand that I have the right to withdraw my application for employment, without prejudice, any time before employment is offered or declined, regardless of whether a prospective employer or I have reviewed my criminal history information.
4.I understand that I may submit to the Commissioner any information that may be relevant to the consideration of my application including, where applicable, information in regard to good conduct and rehabilitation.
5.I have been advised that the criminal history record forwarded to the Commissioner by DCJS and the FBI shall be confidential pursuant to the applicable federal and state laws, rules and regulations and shall not be published or in any way disclosed to persons other than the Commissioner unless otherwise authorized by law. I understand, however, that certain information regarding subsequent arrest notifications received by the Commissioner shall be forwarded to my employing school district, charter school, or board of cooperative educational services.
6.I understand that the fee for DCJS and the FBI to conduct a fingerprint supported criminal history background check is established at $94.25. I can apply for a "fee waiver" from my prospective employer if such fee would cause an unreasonable financial hardship. In order for the Commissioner to process my application, my prospective employer or I must enclose the $94.25 fee by certified check, money order, or school check payable to the New York State Education Department.
7.I have been informed of my right to request that my fingerprints be destroyed when I am no longer employed at a school district, charter school or board of cooperative educational services. I also understand that in the event my employment is terminated and I have not become employed in the same or another school district, charter school or board of cooperative educational services within twelve months of such termination, the Commissioner shall notify DCJS of such termination and the record of my fingerprints for the purpose of employment shall be destroyed.
8.I understand that no clearance for employment will be issued unless my prospective employer has completed Section 3.
9.If I am an applicant for certification, I understand that receipt of my certificate is the only documentation that I will receive indicating that my fingerprints have been cleared, unless I am also seeking clearance for employment and have had my prospective employer complete Section 3.
I have read this consent form and hereby authorize and consent for the Commissioner of Education to use my fingerprints to secure my criminal history record from DCJS and the FBI. I declare and affirm that the fingerprints submitted are my own, and that the information I entered on the fingerprint cards and this consent form is true, complete and accurate. I do authorize NYSED to obtain and review criminal records, including arrests, and dispositions as part of their background investigation of my suitability for employment.
Applicant Signature: |
Date: |
SECTION 6
Name and Address of
Agency Where Fingerprint
Services Performed:
SECTION 7
