I authorize YOUR COMPANY NAME HERE. to perform a criminal history record information check in connection with my work, and to share the information with any / all facilities where I will accept work when required.

Full Legal Name (Current):
Middle Name:
Maiden Name if Applicable:

Tax ID/SS#
Date of Birth:

Zip Code in which you currently live:


Race / Ethnicity:

I hereby release said agency and persons from any and all liability, which may be incurred as a result of furnishing such information. In addition, as an Employee, I will submit a $20.00 money order to cover the cost of this criminal background check to be done. MS Residents will have to send in a $50.00 money order along with a fingerprint card for a federal background check or a MS Fingerprint Clearance letter dated within the last two years as required by the state.

Your Email: