Download PDF sample of this authorization form.

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PLEASE COMPLETE PART A AND B

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Part A

I hereby give my permission for to obtain information relating to my criminal history record. 'Ihe criminal history record, as received from the reporting agencies, may include arrest and conviction data as well as plea bargains and deferred adjudications. I understand that this information will be used, in part, to determine my eligibility for an employment or volunteer position with

I also understand that as long as I remain an employee or volunteer here, the criminal history records check may be repeated at any time. I understand that I will have the opportunity to review the criminal history and a procedure is available for clarification, if I dispute the record as received. I also understand that, by law, I may see a copy of the transcript, for its review:, but may not receive a copy of the document in any fashion or form.

I, the undersigned, do for myself, my heirs, executors and administrators, hereby remise, release and forever discharge and agree to indemnify

and each of their officers, directors, employees, and agents harmless from and against any and all causes of actions, suits, liabilities, costs, debts, and sums of money, claims, demands, whatsoever, and any and all related attorney's fees, court costs, and other expenses resulting from the investigation of my background in connection with my application to become a volunteer or employee of

Please initial in the box if you would like to grant permission to _____________________ to perform a background check for the next 5 years without having to complete this form each year. 'The check will only be done if you are asked to participate on a project with _______________________ .

Print Name ______________________________

Date _____________________________

Applicant's Signature ______________________________

Print Witness Name _____________________________

Witnesses' Signature _____________________________

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Part B

Full Name _____________________________

Physical Address _____________________________

How long have you been at this address? _____________________________

If less than one year, please give previous address _____________________________

Sex: (please indicate) Male Female

Date of Birth: _____________________________

Social Security# _____-_____-_________

Driver License # _____________________________

Have you ever been convicted of a crime? Yes No

Are there any legal charges pending against you? Yes No

If yes, please explain:_____________________________

The signature represents my current legal name and any previously used names are listed below:

Additional Names: _____________________________

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Signature of Applicant _____________________________

Date _____________________________

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