Safe Outdoor Space
Application and Background Check Form
Name
*
First Name
Middle Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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What are your pronouns?
Are you a veteran?
*
Yes
No
Describe why you want to stay in our Safe Outdoor Space?
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Are you currently working with a case manager?
*
Yes
No
What is the name of your case worker and the organization they work for?
*
Do you agree to a background check?
*
Yes
No
Emergency Contact Name
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
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Are you currently employed?
*
Full-Time
Part-Time
I am currently employe
Who is your employer?
*
What questions do you have for us?
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Background and Credit Check Authorization
Please complete the info below.
Date of Birth
*
-
Month
-
Day
Year
Date
Social Security Number
*
Drivers License Number
*
Drivers License State of Issuance
*
Other Names or Aliases
Background and Credit Check Authorization
I hereby authorize NCZ, LLC and his/ her/ its agents and representatives to conduct a review of my background and to obtain a consumer credit report and/or an investigative consumer credit report and any other information necessary for the purposes of a tenant screening. I understand and agree that the information obtained may include, but is not limited to, credit and criminal history, past and present employment and income, bank accounts, credit accounts, credit reports, rental/residence history, references, vehicle records, driving records, criminal records, civil judgment records and any other relevant information. I further authorize previous or current employers, landlords, financial institutions, banks or other companies, public agencies or individuals to release any information, records or data they may have pertaining to me. The information received will be used only for the purposes stated herein and will be maintained in a confidential manner.Pursuant to the Fair Credit Reporting Act (FCRA), if any adverse action is taken based upon information in the consumer report, a copy of the report and a summary of the consumer's rights will be provided to me.A copy, electronic copy, image, or facsimile of this authorization is as valid as the original
Signature
*
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