M A Support Team

Instructions for completing the Name-Based Criminal History Record

Consent Form

In order to pursue the Georgia Statewide criminal search, this form must be completed. Please provide this information as soon as possible to prevent delays. If you have any questions about this form please contact our Candidate Support Team with the contact information listed below. Thank you for your help and quick response. Email: ****************@****.***

Phone: 888-***-****

Fax: 877-***-****

Please follow the instructions below to complete this form. 1. Download the form.

2. Candidate must input the employers name at the top box. 3. The candidate must complete all the required fields: a. Last name

b. First name

c. Middle name

d. Street address

e. City/State/Zip

f. Sex

g. RACE (is required)

h. DOB

i. SSN

4. Candidate must check one box regarding authorization 5. The candidate must electronically sign the form on the Release Authorization Signature line.

6. Candidate must select Purpose Code

7. Submit the completed form by uploading via the upload option on the CandidateConnect® Portal.

Name-Based Criminal History Record Information Consent/Inquiry Form I hereby authorize to conduct a Criminal

History Background inquiry for the purpose listed below and receive any Georgia and/or national criminal history record information as authorized by state and federal law.

** ALL FIELDS ARE REQUIRED

FULL NAME (PRINT) MUST BE CURRENT FULL LEGAL NAME AS IT APPEARS ON GOVERNMENT ID LAST FIRST MIDDLE

ADDRESS

STREET

CITY, STATE ZIP

SEX RACE DATE OF BIRTH SOCIAL SECURITY NUMBER

MALE

FEMALE

UNKNOWN

WHITE

BLACK

ASIAN

HISPANIC

UNKNOWN I HAVE NEVER BEEN ISSUED A SOCIAL

SECURITY NUMBER

CHECK ONE BOX

This authorization is valid for days from the date of signature. I give consent to the above-named entity to perform periodic criminal history background checks for the duration of my employment.

Signature Date

Purpose Code Used: (check one)

NON-CRIMINAL JUSTICE PURPOSES

E – Employment / Volunteer Work / Tenancy

M - Working with Mentally Disabled PROVIDING 24/7 CARE – NOT for Volunteer work N - Working with Elderly – NOT for Volunteer work

W - Working with Children NOT A VOLUNTEER – NOT for Volunteer work ORI STAMP REQUESTED

Contact this candidate