Fingerprinting and Background Check

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Fingerprinting and Background Check
Pre-Processing Form

For Students Only
Faulty, Staff and Adjunct Faculty Please Contact Human Resources

PROGRAM/CATEGORY INFORMATION
Program Name:		Click the drop down menu and choose your Academic Program or Category of Employment
CONTACT INFORMATION
First Name:
Last Name:
Middle Initial:
Street Address:
Address (cont.):
City:
State/Province:
Zip/Postal Code:
Country:	Delete text and replace with country if applicable
Work Phone:
Home Phone:
Email Address:
Date of Birth:	mm/dd/yy
Place of Birth:
Citizenship:	Replace country of citizenship if not United States of America
EMPLOYMENT INFORMATION
Employer Name:
Employer Address:
Employer City:
Employer State:
Employer Zip Code:
Employer Country:
Work Phone:
PERSONAL DEMOGRAPHIC INFORMATION
Gender:	MaleFemale
Race:	Asian-OrientalAmerican Indian-Alaskan NativeBlack WhiteHispanicUnknown
Eye Color:	BrownBlackPinkBlueGray HazelGreenMaroonMulticolored
Hair Color:	BaldSandyGreenWhiteBlackGrayOrange BrownRedPurpleBlondeBluePink
Height:	in feet and inches
Weight:	in pounds (lbs)

Your submission of this information implies consent for its use for the purposes of a background check and related fingerprinting process.

Contact:
Mike Dwyer, Manager North Bay Campus, Room 122 850.769.1551 ext 5608 1.800.311.3682 ext 5608 Email: mdwyer@gulfcoast.edu Fax: 850.873.3556	Pam Keesler, Administrative Assistant North Bay Campus, Room 120 850.747.3242 1.800.311.3685 ext 5609 Email: pkeesler@gulfcoast.edu Fax: 850.873.3556

Gulf Coast Community College
5230 West Highway 98
Panama City, Florida 32401
850.769.1551