Records & Authorization
Consent to Background Check
Authorization and consent for conducting a background check on an applicant. Single signer (applicant).
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# Consent to Background Check **Date:** ___________ ## Applicant Information **Full Legal Name:** ___________ **Date of Birth:** ___________ **Social Security Number (last 4 digits):** ___________ **Current Address:** ___________ **Phone Number:** ___________ **Email Address:** ___________ ## Requesting Organization **Organization Name:** ___________ **Purpose of Background Check:** ___________ ## Authorization and Consent I, the undersigned, hereby authorize the Organization and its designated agents to conduct a background investigation as part of the above-described process. ### Scope of Investigation **Investigation Type:** ___________ The investigation may include but is not limited to: (a) Criminal records (federal, state, and county courts) (b) Sex offender registries (c) Employment history verification
Fields (14)
consent date
date 路 required
applicant name
text 路 required
date of birth
date 路 required
ssn last4
text 路 required
current address
textarea 路 required
phone
text 路 required
email
text 路 required
organization name
text 路 required
purpose
select 路 required
scope
select 路 required
state notices
select 路 required
consent duration
select 路 required
governing state
select 路 required
applicant signer name
text 路 required
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