Criminal History & Background Check Release

1176 Robert T. Longway Blvd., Flint, MI 48503

Name

FIRST NAME Middle Name LAST NAME

MAIDEN NAME OR ALIAS:

ADDRESS:

CITY:

STATE:

ZIP:

DATE OF BIRTH:

Date

GENDER ASSIGNED AT BIRTH

RACE

AFRICAN AMERICAN/BLACK ASIAN AMERICAN INDIAN HISPANIC CAUCASIAN/WHITE PREFER NOT TO SAY

Gender Assigned at Birth

Male Female Non-Binary

DL# *

I hereby give my permission to release information and records to Big Brothers Big Sisters of Flint & Genesee County for the following criminal history checks (CHC) and public domain searches: Genesee County Sheriff’s Department (local), State of Michigan-ICHAT (state), FirstAdvantage Background Verification (national), Secretary of States-Department of Motor Vehicle (driver’s record), Michigan Sex Offender Registry and National Sex Offender Registry. I authorize for these CHC to be completed EVERY THREE (3) YEARS from my match anniversary date.

SIGNATURE:

Clear

DATE:

Date

SS#

AUTHORIZATION FOR RELEASE OF INFORMATION