Criminal History Report
Under the provisions of the Fair Credit Reporting Act, 15 USC, Section 1681 et seq., the Americans with Disabilities act and all applicable federal, state and local laws, I hereby authorize and permit DETROIT RECOVERY PROJECT to obtain a criminal history report.I agree that a copy of this authorization has the same effect as the original.I hereby release and hold harmless any person, firm, or entity that discloses matters in accordance with this authorization, as well as DETROIT RECOVERY PROJECT from liability that might otherwise result from the request for use of and/or disclosure of any or all of the foregoing information.I understand and acknowledge that under provision of the Fair Credit Reporting Act, I must request a copy of any criminal history report from the consumer reporting agency that compiled the report, after I have provided proper identification.I hereby authorize DETROIT RECOVERY PROJECT to obtain a criminal history report as set forth above, as part of its investigation of my employment application. This authorization is valid as long as I am an employee or employee candidate.This authorization shall remain in effect over the course of my employment. Reports may be ordered periodically during the course of my employment by DETROIT RECOVERY PROJECT.
Full Name of Job Applicant/Employee:
First Name
Middle Name
Last Name
Date of Birth
Please select a month
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Please select a year
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Please check all the apply:
Hispanic or Latino
White (not Hispanic or Latino)
Black or African American (not Hispanic or Latino)
Native Hawaiian or Pacific Islander (not Hispanic or Latino)
Asian (not Hispanic or Latino)
American Indian or Alaskan Native (not Hispanic or Latino)
Two or More Races (not Hispanic or Latino)
Have you lived outside the State of Michigan in the past 3 years (check one):
Yes
No
Have you been a resident of the State of Michigan for the past 3 years (check one)
Yes
No
I consent for the Michigan Department of State Police to conduct a criminal history check regarding me under Public Health Code Section 20173, and I agree to provide to DETROIT RECOVERY PROJECT identification acceptable to the Michigan Department fo State Police.
Print Name of Applicant
First Name
Last Name
Signature of Applicant
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: