Town Of Amherst, National Background Screening Consent Form


Town of Amherst
Amherst Parks and Recreation Department
4 Cross Road
Amherst, NH 03031
Background Check Consent and Release Waiver
National Background Screening Consent Form
Applicant’s Legal Name (printed)
Social Security Number __________________ Date of Birth _________
Applicant’s Address
City ___________________________State _________Zip __________
I, ____________________________, authorize and give consent for the above named
organization to obtain information regarding myself. This includes the following:
 Local & National Criminal background records/information
 All 50 State Sex Offender Registries
 Full Address Trace
 Social Security Verification
I, the undersigned, authorize this information to be obtained either in writing or via
telephone in connection with my application. Any person, firm or organization providing
information or records in accordance with this authorization is released from any and
all claims of liability for compliance. Such information will be held in confidence in
accordance with the organization’s guidelines.
By signing this document, I am providing the above named Organization my consent
for an initial background check as well as any subsequent background checks deemed
necessary throughout the length of my volunteer/employment assignment with this
Print Name: _______________________________Date:_______________
Signature: _____________________________________________________


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