Global Hr Criminal

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. Full Name (print)

Address

Sex Race Date of Birth 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

M - Working with Mentally Disabled PROVIDING 24/7 CARE N - Working with Elderly

W - Working with Children NOT A VOLUNTEER

x

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