Consent For Background Investigation - Volunteers - 2014 Page 2
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2CONFIDENTIAL
Background Check Authorization – Please Print Clearly
Print Name: ___________________________________________________________________________
(First)
(Middle)
(Last)
Former Name(s) and Dates Used: _________________________________________________________
Social Security Number: _________-____________-___________
Date of Birth: ____/_____/_______
Sex: ______________________ Driver’s License Number/State: _______________________________
Telephone Number: (_____)_____-______ Volunteer Role(s) Applied For: _________________________
Current Address: ___________________ ___________________________________________________
Dates: From/ to Current
(Street Address)
(City)
(Zip/State)
(County/Borough)
Previous Address: ___________________ __________________________________________________
Dates: From/To
(Street Address)
(City)
(Zip/State)
(County/Borough)
Previous Address: ___________________ __________________________________________________
Dates: From/To
(Street Address)
(City)
(Zip/State)
(County/Borough)
Please list any states you have lived in other than Alaska (include counties and dates of residence):
______________________________________________________________________________________
______________________________________________________________________________________
Have you had any motor vehicle violations in the past three (3) years?
Yes ____ No _____
Have you ever been convicted of or pled guilty or no contest to a criminal charge?
Yes ____ No _____
Are you currently awaiting trial, sentencing, or disposition of a criminal charge?
Yes ____ No _____
Have you ever been a defendant in a civil action for intentional tort(s) (Including but not limited to battery,
assault, false imprisonment, defamation, fraud, conversion)?
Yes ____ No _____
If you answered Yes to any of the last three (3) questions above, please provide the Case Numbers, Date
of Action, Disposition, Place of Occurrence, and Current Status below. (If more space is needed, please
use reverse side of this authorization.)
______________________________________________________________________________________
______________________________________________________________________________________
Volunteer Applicant Acknowledgment and Authorization
By my signature below, I confirm that I have received and understand the KPB Volunteer Background Check Policy
and agree that the information provided on this form to the Kenai Peninsula Borough is true and correct. I give my
consent to the KPB to conduct a background check as described in this authorization.
Printed Name _________________________________________________________
Signature ____________________________________________________________
Date ___________________
KPB Consent for Background Investigation – Volunteers – April 2014
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