DISCLOSURE AND CERTIFICATE OF APPLICANT

Name:__________________________________________________________________

Social Security #:_____________________ or Employee I.D. # ____________________

Address:________________________________________________________________

City/State:_______________________________________________________________

Telephone Number:_______________________________________________________

Have you ever been convicted of or pled guilty or nolo contendere/no contest to any felony?     Yes:_____         No:_______

If yes, please explain:______________________________________________________

________________________________________________________________________

Have you ever been convicted of or pled guilty or nolo contendere/no contest to a sex crime

against a minor or a sex crime involving violence?              Yes:_____         No:_______

If yes, please explain:______________________________________________________

________________________________________________________________________

If the answer above is "yes", you must provide a certified copy of conviction and any other pertinent, clarifying documents to the Human Resources Department.

I understand, agree and certify that:

All information given within my application materials, supporting documents and interview are correct to the best of my knowledge.  I understand that giving false information may disqualify me from consideration of employment or discharge, if hired,  regardless of when discovered.  I further authorize the university to investigate all statements made throughout the application process for employment.  I authorize such educational institutions, employers and others (and their agents or employees) to respond to questions concerning information I have given throughout the application process.  And I further release from liability the University of Wyoming, such former employers, institutions, or persons providing such information. 

Signature:_____________________________________Date:______________________

Updated 10/1/08