Criminal Background Check

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CRIMINAL BACKGROUND CHECK
Pennsylvania School Boards Association
A service of the
CANDIDATE INFORMATION (please print legibly):
Name* __________________________________________________________________________________________
First Name*
Middle Name
Last Name*
Date of Birth*____________ Social Security Number (highly recommended)_____________________________
Address* (must live in PA for no less than 2 yrs)
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Aliases or Maiden Name _______________________________
*REQUIRED FOR CRIMINAL HISTORY BACKGROUND CHECK
REQUEST SUBMITTED BY:
Name __________________________________________ Title __________________________________________
School Entity ____________________________________________________________________________________
Address _________________________________________________________________________________________
Phone ___________________________________________ Fax __________________________________________
E-mail Address __________________________________________________________________________________
The cost for this service is $20 per criminal background check
r
r
r
r
I am enclosing a check
Credit Card:
Visa
MasterCard
for $___________. Make check
Card# ____________________________________________________
payable to Pennsylvania
School Boards Association.
Exp. Date ________ Billing Zip Code _______________________
Name on Card ____________________________________________
r
Please bill my school entity.
A minimum of three background
checks is required to bill your
Q
school entity.
uestions? Call (800) 932-0588; Michelle Kunkel, ext. 3365
or Britta Barrickman, ext. 3369
FAX
(717) 506-2476 – Attn: Michelle Kunkel
t
E-MAIL
MAIL
Attn: Michelle Kunkel
Same-day service is contingent on
Pennsylvania School Boards Association
availability of the Pennsylvania
400 Bent Creek Blvd.
State Police system. You will be
Mechanicsburg, PA 17050-1873
notified if your request cannot be
processed for any reason.
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