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Fingerprinting and Background Check
Pre-Processing Form

For Students Only
Faculty, 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:

 

Middle Name:

 

Last Name:

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:

Race:



Eye Color:



Hair Color:



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