Alacourt Background Check- Release Authorization

ALACOURT BACKGROUND CHECK- RELEASE AUTHORIZATION

APPLICANT TO COMPLETE THE FOLLOWING:

THE FOLLOWING INFORMATION IS REQUIRED BY LAW ENFORCEMENT AGENCIES AND

OTHER ENTITIES FOR POSITIVE IDENTIFICATION PURPOSES WHEN CHECKING PUBLIC

RECORDS. IT IS CONFIDENTIAL AND WILL NOT BE USED FOR ANY OTHER PURPOSES.

PLEASE PRINT CLEARLY

FIRST NAME: ______________________ MIDDLE NAME: _________________________

LAST NAME: ________________________________

OTHER NAMES, I.E., MAIDEN NAME: _______________________________________________________

ADDRESS_____________________________________________________________________________

CITY____________________________________ STATE_________ ZIP CODE_______________

SOCIAL SECURTIY NUMBER: ________________________________________

DATE OF BIRTH: _______________________________________

YOUR SIGNATURE: _______________________________________ TODAY’S DATE: ________________

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Parent category: Legal