Authorization And Request For Criminal Records Verification And Fingerprint Information
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1AUTHORIZATION AND REQUEST FOR
CRIMINAL RECORDS VERIFICATION AND FINGERPRINT
INFORMATION
I, _________________________, hereby authorize __________________________________
to obtain and/or request information about my criminal history and fingerprints from any entity chosen
specifically for conducting this search, to release information regarding any record of charges or
convictions contained in its files, or in any criminal file maintained on me, whether said file is a local,
state, or national file, and including but not limited to accusations and convictions for crimes committed
against minors, to the fullest extent permitted by city, county, state, and federal law. I do release said
entities from all liability that may result from any such disclosure made in response to this request. I
may revoke this request at any time, but that revocation must be in writing and give 30 days' notice of
same.
Signature of Applicant: __________________________________ Date:__________________
Name (Last)
(First)
(Middle)
Address
City
State
ZIP Code
Other names used by applicant (if any):
Date of Birth
Place of Birth
Social Security Number
Driver's License No.
Issuing State
License expiration date
H
S
B
CHURCH MUTUAL INSURANCE COMPANY AND
ERMES
ARGENT
ATES WISH TO POINT OUT THAT NO WARRANTY ATTACHES TO
,
,
THESE DOCUMENTS
AND IN FACT
THESE DOCUMENTS MAY NOT BE APPROPRIATE FOR THE SPECIFIC NEEDS OF A PARTICULAR
.
,
,
ENTITY
THESE DOCUMENTS ARE NOT A SUBSTITUTE FOR GOOD PRACTICE
PROPER SUPERVISION
AND DILIGENT OVERSIGHT
.
.
AND CONTROL
THERE IS NO GUARANTEE THAT THESE DOCUMENTS WILL PROTECT ANY FACILITY THAT CHOOSES TO USE THEM
,
BEFORE USING THESE DOCUMENTS OR ANY SIMILAR DOCUMENTS
YOU SHOULD CONSULT WITH YOUR OWN ATTORNEY TO MAKE
CERTAIN THAT THE DOCUMENT YOU EVENTUALLY USE IS CORRECT AND CURRENT UNDER THE LAW OF YOUR PARTICULAR
.
JURISDICTION AND THAT THE DOCUMENT MEETS YOUR NEEDS FOR YOUR PARTICULAR SITUATION
FM:S870 (8-2008) HSB
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