Background Information Request And Waiver - Sheriff'S Department

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BACKGROUND INFORMATION REQUEST AND WAIVER
(PLEASE PRINT CLEARLY OR TYPE)
NAME
LAST
FIRST
MIDDLE
PREVIOUS NAME AND/OR ALIAS
RESIDENTIAL ADDRESS
(Not a P.O. Box)
NUMBER
STREET
CITY
STATE
ZIP
HAVE YOU EVER RESIDED IN ANOTHER STATE?
IF YES, WHICH STATE(S)
SOCIAL SECURITY NUMBER
DRIVER’S LICENSE NUMBER STATE
DATE OF BIRTH
PLACE OF BIRTH
SEX
RACE
Contact Number
MOTHER’S MAIDEN NAME
FATHER’S NAME
I,
, hereby release, discharge, and exonerate the Essex County
Sheriff’s Department, its agents and representatives, and any person so furnishing information, for any and
all liability of every nature and kind arising out of furnishing or inspection of such documents, records and
other information or the investigations made by or on behalf of the Essex County Sheriff’s Department.
I further understand that the Essex County Sheriff’s Department will conduct a background investigation
which may include a check with past employers, a criminal records check with the lo cal police department,
the State Police, the FBI in Washington, D.C. the Massachusetts Board of Probation and Registry of Motor
Vehicles. The Essex County Sheriff’s Department will conduct these checks as the Department deems
necessary.
Witness
Signature

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