An Administrator's Guide to California Private School Law Compendium

D OCUMENT 3.D

S AMPLE E LECTION F ORM T O R ECEIVE /N OT R ECEIVE P UBLIC R ECORDS [I N -H OUSE R EFERENCE C HECK ] I, ________________________ (print applicant name), authorize all current and former employers and/or their agents to respond candidly to verbal and/or written inquiries from [SCHOOL] regarding my employment record, including but not limited to: job positions held; dates of employment; disciplinary records, including any records which have been sealed as part of a settlement; reason(s) for ending prior employment; and work performance records including information regarding reliability, incidents of dishonesty, insubordination, violence, and/or unsafe behavior and harmful or threatening behavior. I am aware that [SCHOOL] may obtain “public records” regarding me for employment purposes, including but not limited to evaluation for employment, assignment and/or promotion. I acknowledge that the term, “public records,” as used herein is limited to records of: arrest, indictment, conviction, civil judicial action, tax lien or outstanding judgment. PLEASE CHECK ONE BOX ONLY:  I hereby elect to receive any public records which may be obtained by [School] for employment purposes under Civil Code section 1786.53. I acknowledge that [School] must provide me with a copy of any public records within seven (7) days of [School’s] receipt of such records.  I hereby elect NOT to receive any public records which may be obtained by [School] for employment purposes under Civil Code section 1786.53. __________________________________ ___________________________________ Applicant signature Date Social Security # ____________________ This authorization expires:____________________

An Administrator’s Guide to California Private School Law - Compendium ©2019 Liebert Cassidy Whitmore 65