SECTION 1 – Applicant Information
Applicant Full Name:
Other Names Currently Used or Previously Used:
Current Phone Number:
Current Home Address:
Past Home Addresses: (last five years)
Current Work Address:
Past Work Addresses: (last five years)
Schools Attended: (high school and beyond) (Name of School, City and State)
SECTION 2 – Applicant Agreement
I have applied for a position with the Virginia Department of Forestry which has been designated as “sensitive” or that will have access to sensitive information. This designation permits the agency to conduct a fingerprint-based criminal history check. In order to establish work-related, internet accounts prior to my fingerprints being processed, I authorize any investigator or duly accredited representative of the Virginia Department of Forestry bearing this release, or a copy thereof, to obtain information from online court records, and report the results to the designated representative of the agency. I direct that such information be released upon request to the bearer of this form. I understand that the information released is for official use by the Virginia Department of Forestry. I release any individual, including records custodians, from any and all liability for damages of whatever kind or nature that may at any time result to me on account of compliance, or any attempt to comply, with this authorization. Should there be any question as to the validity of this release, you may contact me as indicated below. I understand that any and all information collected pursuant to this background check may be used in assessing my suitability for the position for which I have applied. The information will not be shared with parties outside of the agency where the position is located. I further understand that I may challenge the results of the online search and may request information needed to make such a challenge from the Virginia Department of Forestry. By signing below, I agree to provide the following accurate information so the online search may commence:
Date of Birth:
Applicant Name (Print)	Applicant Signature	Date
Email or fax to VDOF Human Resources Office, Tammi Oliva ; tammi.oliva@dof.virginia.gov ; Fax 434-977-7749