HomeMy WebLinkAboutBackground Authorization Form_2023 CITY OF LANSING
DEPARTMENT OF HUMAN RESOURCES
8th Floor, City Hall . Benefits/Classifications (517) 483-4004 (Voice/TDD)
124 W. Michigan Avenue Labor Relations/Recruitment (517) 483-6064 (General Fax)
Lansing, Michigan 48933 Safety/Selection/Training www.lansingmi.gov (Website)
Worker’s Compensation
“Equal Opportunity Employer” Rev: 01/30/23
Elizabeth O’Leary,
HR Director
Background Check Authorization Form
Dear Applicant/Employee:
As part of the selection process for this position, we need you to complete the background and criminal history record
check authorization listed below. This information must be returned with your application to the Department of Human
Resources 8th Floor City Hall, 124 W. Michigan Avenue, Lansing, MI 48933. We appreciate your help regarding this
matter. Please call us at (517) 483-4004 if you have any questions.
_______________________________________________________________________________
Date: _________________________________
I, _________________________________________, authorize the release of any and all information from any
appropriate agency regarding any criminal conviction history to the City of Lansing Department of Human Resources.
I understand that my ethnicity, date of birth, gender, and my age will not be made a part of my Employment
Application and that none of these four (4) items will be considered in the review of my employment.
I acknowledge that the City will complete a full background investigation, including but not limited to a State Police
Criminal Conviction Record Check and Secretary of State Record Check.
I further understand that the City of Lansing has the right to either withdraw any conditional offer of employment or
terminate employment based upon the results of this investigation.
________________________________
(Signature)
_____________________________________________________________________________________________
First (Please Print) Middle Last Birth Name
Other name(s) you may have used or worked under ___________________________________________________
Date of Birth ___________ Social Security # ________________ Sex M / F Ethnicity ____________
Driver License # ___________________________ Driver’s License Type ________________ Exp. Date _________
Do you have a CDL License? _____If so, what type and what endorsements? ______________________________
Position applied for? ________________________________________________ Driving required? Yes ___ No ___
For office use only:
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Returning Volunteer Returning Staff
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