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:
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.
By clicking Sign & Send below you agree to the terms contained herein, and that terms are binding in your jurisdiction as defined in our Electronic Signature Disclosure & Consent
Document Blockchain ID: cCI3Amjt2K3OgZc3WGQLIgkvvimegDIFKsEOLO0rNNs1wfElMQp8aJbRkmS0n13y, Signed on: , Signor 1 given identity: [email protected], email verified by user, Login with Google Secure OAuth, IP Address: , Via browser: , Running on: , Language: , Timezone: , Resolution: , Destruction Date: , Document last modified prior to signature:
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Acknowledgement of your access and consent to electronic records and electronic signature
By clicking "Sign & Send" on any document posting to this service, you agree that
Electronic Signature Disclosure & Consent