Sample Criminal Background Disclosure Informed Consent Form printable pdf download

Sample Criminal Background Disclosure Informed Consent Form

Sample Informed Consent Form

Company Name

Street Address

City, State, Zip

Phone

Contact Person

Date:

The following named individual has made application with this agency for

(employment)

Last Name of Applicant

(please print)

First Name

(please print)

Middle (Full)

(please print)

Maiden, Alias or Former

(please print)

Date of Birth:

Sex (M or F):

(Month/Day/Year)

Social Security Number:

I authorize the Minnesota Bureau of Criminal Apprehension to disclose all criminal history

record information to (Company Name or Specific Individual) for the purpose of (employment)

with this agency as ________________________________ pursuant to Minnesota state statute

299C.72.

The expiration of this authorization shall be for a period no longer than one year from the date of

my signature.

Signature of Applicant

Date

Note: This form is meant as an example of the type of informed consent that is acceptable. Your

agency is responsible for designing the form to reflect the information that is needed for the

Bureau of Criminal Apprehension to perform criminal history checks. Please use this sample as

a guideline when creating your form.

Sample Criminal Background Disclosure Informed Consent Form