Fillable Cal North Soccer Live Scan Form printable pdf download

Cal North Soccer Live Scan Form

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Cal North Soccer

Live Scan Form

CONTRACT CODE:

GAJR

Applicant Must Complete The Section Below

(Print in CAPITAL LETTERS

)

JOB TITLE :

Coach_____

Board Member_____

Referee_____

Volunteer_____

Applicant:

Last Name:

Date of Birth:

First Name:

Gender:

Middle Name:

Eye Color:

Suﬃx:

Hair Color:

CDL Or ID #:

Height:

Alias:

Weight:

Home Address:

Apt #:

Street Address:

Zip:

State:

City:

OCA / Your Number:

District Number

League Number

Club Number

I request to be ﬁngerprinted so I may qualify to volunteer for or be employed by California Youth Soccer Associating (Cal North) or operate under contract with

one of our aﬃliate organizations. I also certify that I have no physical illness or impairment which will make participation in soccer related activities dangerous to

me. I understand that in requesting and being ﬁngerprinted I may be disqualiﬁed or terminated (’Fail’) from volunteering or employment if, according to the

guidelines approved by the Board of Directors, the results of the background check and the review process shows evidence of moral turpitude, dishonesty, or

fraud to such a degree as to cause the Board to be concerned for the well-being of those who would be associated with me as a volunteer.

I understand that I am required to complete the Cal North 1650 Form - Risk Management Disclosure and Agreement that outlines the complete policies and

procedures pertaining to my request to be ﬁngerprinted under the Cal North Risk Management Program.

I declare under Penalty of Perjury under the laws of the State of California that the information that I have furnished on this form is true and correct to the best

of my knowledge.

Signature:___________________________________________________________________________________________

Date:_________________________________________

Live Scan Agency Name

Live Scan ID (LSID)

Date

Name of Operator

ATI Number

OATI (Resubmission Only )

For information, locations or appointments please visit our website:

Or email us at:

For NON SAMS locations please use ORI#AE689