This form should be submitted by UMMC employees and non-employees to disclose any
changes to their criminal history record that may have occurred since the time of receiving fingerprint
clearance. All have an affirmative obligation to immediately disclose any changes to their criminal
history record including charges resulting from arrests, criminal convictions of both misdemeanor and
felony crimes, and addition to a sex offender registry. UMMC students should not utilize this
form, but should instead disclose any criminal history record changes to the Dean of their Program
of Studies or their designee.
This form will be securely routed to the Human Resources Employee Relations for review. It
is important that you include information about the disposition of the event (guilty,
nolo contendere, non-adjudicated, charges are pending, etc.). You may use the attachment option
to attach any relevant court documents, police records, or other official documents for
consideration. |
| Attachment |
*.txt,*.doc,*.docx,*.xls,*.xlsx,*.pdf, *.gif,*.jpg,*.jpeg,*.bmp,*.png,*.tif,*.tiff |
| Attachment |
*.txt,*.doc,*.docx,*.xls,*.xlsx,*.pdf, *.gif,*.jpg,*.jpeg,*.bmp,*.png,*.tif,*.tiff |
| Attachment |
*.txt,*.doc,*.docx,*.xls,*.xlsx,*.pdf, *.gif,*.jpg,*.jpeg,*.bmp,*.png,*.tif,*.tiff |
| By submitting this form, I attest that the information that I have provided is
true and accurate. I understand that my clearance to work at UMMC may be revoked at any time
in response to this disclosure. I release UMMC and its agents, officers, employees, attorneys,
and representatives of all liability associated with work authorization decisions or actions
based in whole or in part on compliance with or attempts to comply in good faith with the
requirements of Miss. Code Ann. § 37-115-41, 45-33-59, or 43-11-13. |