Background Verification Release Form
AGENCY INFORMATION
Date *
MM
/
DD
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YYYY
APPLICANT INFORMATION
Applicant Full Name (Last, First, MI) *
Your answer
Maiden or Other Name(s) Used *
Your answer
Current Address *
City, State, Zip Code
Your answer
County of Residence *
Your answer
Social Security Number *
Your answer
Date of Birth *
Your answer
Driver's License Number and State of Issue *
Your answer
Gender *
Required
Race *
Required
Authorization and Release
I give authorization to the complete release of these records as described above. *
Type in your name below indicating your authorization.
Your answer
Parent/Guardian's Signature (if under 18 years of age)
Type in parent/guardian's name below giving authorization.
Your answer
*
MM
/
DD
/
YYYY
Additional Information
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