Criminal History Authorization Form

Criminal History Authorization Form
This form is used to obtain authorization from individuals to conduct a criminal history check. All information will be kept confidential and used only for the purpose of conducting a criminal history check.
Full Name
First NameLast Name
Date of Birth
MonthDayYear
Date
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip CodeCountry
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
I, the undersigned, authorize the release of any and all criminal history information about me, including any and all records of arrests, charges, and convictions, to the organization named below for the purpose of conducting a criminal history check. I understand that the criminal history information will be used for employment-related purposes only, and I release all individuals, agencies, and organizations from any and all liability for providing such information. I understand that this authorization is valid for the duration of my application process and for any future employment with the organization named below.
Organization Name
Date
MonthDayYear
Date
Signature
Clear
Should be Empty: