Law Enforcement Background Check Form

Law Enforcement Background Check Form
Please complete this form to authorize a law enforcement background check. All information provided will be handled confidentially.
Full Name
First NameLast Name
Date of Birth
MonthDayYear
Date
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Current Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Previous Address (if lived at current address less than 5 years)
Employment History (last 5 years)
Reason for Background Check
Other
Have you ever been convicted of a crime?
If yes, please provide details (offense, date, location):
Reference Name
First NameLast Name
Reference Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Applicant Signature
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Should be Empty: