Authorization For Release Of Information printable pdf download

YWCA of Seattle - King County - Snohomish County

Authorization for Release of Information

Washington State Patrol Identification and Criminal History Section

PO Box 42633, Olympia, WA 98504

Phone: (360) 534-2000

During the application process and at any time during the tenure of my volunteer placement with YWCA

of Seattle - King County - Snohomish County, I herby authorize Washington State Patrol, on behalf of

YWCA of Seattle - King County - Snohomish County to procure a consumer report (background check)

which I understand it may include information regarding my credit worthiness, credit standing, credit

capacity, character, general reputation or personal characteristics. This may be complied with information

from credit bureaus, court record repositories, past or present employers and educational institutions,

governmental occupational licensing or registration entities, business or personal references, and any

other source required to verify information that I have voluntary supplied. I understand that I may request

a complete and accurate disclosure of the nature and scope of the background verification to the extent

such investigation includes information bearing on my character, general reputation or personal

characteristics.

To conduct the criminal record check, the following information is required:

(

)

PLEASE PRINT LEGIBLY

Last Name:

First Name:

Middle Name:

Alias and/or Maiden:

Date of Birth

Current Address: (City, County, State, Zip)

How Long?

Previous Address: (City, County and State for the last 10 years)

I hereby certify that all information provided in this authorization is true, correct and complete. I

understand that if any information proves to be incorrect or incomplete that grounds for the canceling of

any offers of volunteer placement and may be used at the discretion of the volunteer site.

Signature____________________________________________ _______ Date___________________

- - - - - - - - - - - - - - - - - - - - - - [ Volunteer Engagement Department Use Only ] - - - - - - - - - - - - - - - - - - -

Date Completed: _____________

Completed By: ________________________________

 Felony  Misdemeanor  Civil  Fed  Other

 Clear, No Records Found

 Not Clear, Records Found

 EPLS

Authorization For Release Of Information