(SAMPLE FORM)
Applicant Criminal Records Consideration Form
In compliance with BBBBBBBBBBBBBBany employer who withdraws a conditional offer of employment after
conducting a criminal history inquiry on an applicant must provide the applicant with a copy of the results
of the criminal history inquiry and a completed copy of this form. In accordance with BBBBBBBBBBBBBBBBB,
WKHHPployer must consider the 5 factors below in reviewing the applicant’s criminal history. Once the
applicant has received appropriate notice from a prospective employer of a withdrawn offer because of
the results of a criminal history inquiry, that prospective employee shall have 10 days to dispute the
results of the criminal history inquiry or respond with additional factors for consideration. Employers
must keep a copy of this form in their records for 24 months from the date of completion.
Please consider the following 5 factors as you complete this form.
I.
II.
III.
IV.
V.
The nature of the crime and its relationship to the duties of the position sought or held
Any information pertaining to the degree of rehabilitation and good conduct, including any
information produced by the candidate or employee, or produced on his or her behalf.
Does the prospective job provide an opportunity for the commission of a similar offense(s)?
Are the circumstances leading to the offense(s) likely to reoccur?
How much time has elapsed since the offense(s) and how did you factor that into the
employment decision?
1. What position does the applicant seek?
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2. What are the duties of that position?
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3. What crime(s) were present in the applicant’s criminal history?
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4. For the crime(s) listed in the applicant’s criminal history, please discuss how you considered each
of the following:
i. What evidence has the candidate shown of rehabilitation?
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ii. Does this position give the applicant an opportunity to commit similar offenses?
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iii. How much time has elapsed since the last criminal activity in the applicant’s report?
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