GCIC Consent Form
Please read and fill out the following consent form.
Name
First Name
Last Name
Date of Birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Gender
Please Select
Male
Female
N/A
Previous Names Used & Time Periods
You Must Check One Below
This authorization is valid for 90 Days / 180 Days (Circle One) from signature date.
I give consent to perform periodic criminal history checks for the duration of my employment with this company.
Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature
Submit
Should be Empty: