WIN Consent to Perform Criminal Background Check

Full Name*

First NameMiddle NameLast Name

Maiden Name*

First NameMiddle NameLast Name

Other Names You Have Used

First NameMiddle NameLast Name

Other Names You Have Used

First NameMiddle NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

County where you currently reside*

County

Phone Number*

Area CodePhone Number

E-mail*

Birth Date*

MonthDayYear

Are You a U.S. Citizen?*

YesNo

Convicted Of A Felony?*

YesNo

If So Please Explain

Please enter Driver's License*

Driver's License Number

Please enter your Social Security Number*

Gender Identity*

In the table below, please list all counties and states in which you resided since 18 years of age or high school graduation.

Dates must be specific mm/dd/yyyy format. If you are unsure of exact dates, provide best estimated dates *

I, First Name Last Name , am an applicant for volunteering with Women In Need and have been advised that as a part of the application process, Women In Need conducts a criminal history background check. I do, hereby, consent to Women In Need using any information provided during the application process in performing the criminal history check.
I, __ First Name Last Name , have been informed by Women in Need that I have the right to review and challenge any negative information that would adversely impact Women in Need’s decision to all me to volunteer with the organization. I have also been advised that Women In Need will give me a reasonable opportunity to clear up any mistaken information reported. However, I do understand that time is of the essence and reasonableness of time is within the sole discretion of the District.
I understand that the information I am providing about age and sex will be used solely for the purpose of obtaining criminal history record information.

Signature*