Permit Form For National Background Screening
Legal Name Of Applicant ———————————————————-
Social Security Number———————– Date Of Birth ——————
City—————————— State ————————— Zip —————–
I ‘————————————’ authorize and consent to the above-mentioned organization obtaining information about me. This contains the following items:
1. Local and National Criminal Background Records.
2. All State Sexual Offender Registries.
3. Full Address Detail.
4. Social Security Identification.
I, the undersigned, authorize this information to be obtained in writing or over the phone in connection with my application. Any person, firm or organization that provides data or records in accordance with this authorization is published from any and all claims of responsibility for compliance. Such information will be kept confidential in accordance with the organization’s policies.
By signing this document, I give the above-mentioned organization my permission to conduct an initial background check as well as any successive background checks considered necessary during the duration of my volunteer/employment assignment with this organization.
Print Name _____________________________ Date ______________________