Background Release Form

Background Release Form

Please enter your full legal name as it appears on your Social Security Card.
Name:

First NameMiddle NameLast Name
Aliases (Other Name) / Maiden Name:
Social Security Number:
Date of Birth:

MonthDayYear
Current Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Country of Birth:
If United States, State of Birth:
Please provide prior out-of-state addresses for the last five years.
Previous Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please attach a photo of your Driver's License / State ID:

Cancelof
Driver's License # / State ID #:
State:
Expiration Date:
Position (Select all that apply):
I hereby state that I have read the Background Study Privacy Notice.

I HAVE RECEIVED INSTRUCTION TO HAVE MY FINGERPRINTS COMPLETED
Employee Signature:
Date:

MonthDayYear
Should be Empty: