178 Columbia St, Chester, SC 29706
803-209-8667
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Criminal Background Check and Sworn Statement of Affirmation
Employee First Name *
Employee Middle Name
Employee Last Name *
Maiden Name — First
Maiden Name — Middle
Maiden Name — Last
SSN (123-45-6789) *
Street Address *
City *
State/Region/Province *
Postal / Zip Code *
Have You Ever Been Convicted of a Law Violation (excluding juvenile offenses)? *
-Select-
Yes
No
If Yes, List All and Explain
Are You the Subject of Any Pending Criminal Charges? *
-Select-
Yes
No
If Yes, List All and Explain
Date-Time
Employee Signature — type your full legal name to sign *
I swear the above statements are true and this constitutes my sworn statement of affirmation *
Submit