504 A4 Disclosure of Information Received from GCIC and/or FBI

[Date]

[Name]

[Address]

Dear [Applicant/Employee Name],

A criminal history record check was conducted on you as a condition of employment with the Department of Human Services, [Insert DHS Organizational Unit]. Information received from the Georgia Crime Information Center (GCIC) and/or the Federal Bureau of Investigation (FBI) [Only include the applicable agency] indicates the following pending charge(s) and/or conviction(s) in your record:

In accordance with the Rules of the GCIC Council, this letter serves as notice that you will not be employed with the Department of Human Services based on the above information.

Sincerely,

Name
Title

Note to Hiring Officials:

All applicants removed from employment consideration due to criminal history record checks must be given this disclosure notice. If an offer of employment has been made, a letter withdrawing the offer of employment in addition to this disclosure notice must be issued to the applicant. The letter is to be filed with the applicant’s record. The disclosure notice must be filed in a separate file.