Background Consent/Release Form
1
*Parental/Guardian signature is only required for appl icants who are les s than 18 years of Background Consent/Release Form Organization ____________________________________________________________ Applicant’s Legal Name (printed) ____________________________________________________________________ ____ Social Security Number ________________________ Date of Birth ______________ Applicant’s Address ____________________________________________________________________ ____ City __________________________________ State __________ Zip _____________ I, ____________________________, authorize and give consent for the above named organization to obtain information regarding myself. This includes the following: • Criminal background records/information • Sex Offender Registry Checks • Addresses • Social Security Verification I the undersigned, authorize this information to be obtained either in writing or via telephone in connection with my application. Any person, firm, or organization providing information or records in accordance with this authorization is released from any and all claims of liability for compliance. Such information will be held in confidence in accordance with the organization’s guidelines. Print Name (Applicant): ______________________________________________ Date:____________________ Signature: ____________________________________________________________________ ____
description
Background Consent/Release Form Organization ____________________________________________________________ Applicant’s Legal Name (printed) ________________________________________________________________________ Social Security Number ________________________ Date of Birth ______________ - PowerPoint PPT Presentation
Transcript of Background Consent/Release Form
*Parental/Guardian signature is only required for applicants who are less than 18 years of age.
Background Consent/Release Form
Organization ____________________________________________________________
Applicant’s Legal Name (printed)________________________________________________________________________
Social Security Number ________________________ Date of Birth ______________
Applicant’s Address________________________________________________________________________
City __________________________________ State __________ Zip _____________
I, ____________________________, authorize and give consent for the above named organization to obtain information regarding myself. This includes the following:
• Criminal background records/information• Sex Offender Registry Checks• Addresses• Social Security Verification
I the undersigned, authorize this information to be obtained either in writing or via telephone in connection with my application. Any person, firm, or organization providing information or records in accordance with this authorization is released from any and all claims of liability for compliance. Such information will be held in confidence in accordance with the organization’s guidelines.
Print Name (Applicant):______________________________________________ Date:____________________
Signature:________________________________________________________________________
Print Name (Parent or Legal Guardian*):______________________________________________ Date:____________________
Signature:________________________________________________________________________*Parental/Guardian signature is only required for applicants who are less than 18 years of age.
