Criminal background form .pdf

PHIL MILLER
DOUGLAS COUNTY SHERIFF’S OFFICE
6840 WEST CHURCH STREET
DOUGLASVILLE, GA 30134
770/942-2121
Fax 770/920-3120
CRIMINAL BACKGROUND CHECK CONSENT FORM
2016
I HEREBY AUTHORIZE:
Bill Arp Recreation Club TO RECEIVE ANY CRIMINAL HISTORY RECORD INFORMATION
PERTAINING TO ME WHICH MAY BE IN THE FILES OF ANY STATE OR LOCAL CRIMINAL JUSTICE AGENCY IN THE
STATE OF GEORGIA.
Please print neatly
I AM REQUESTING THIS INFORMATION FOR: Coaching / Team mom Bill Arp Little League Baseball/Softball

POSITION / AGE DIVISION:

NAME:
LAST

FIRST

MIDDLE

ADDRESS:
STREET

CITY

SEX

STATE

RACE

ZIP

DATE OF BIRTH

SOCIAL SECURITY NUMBER

Race Codes:
I = American Indian or Alaskan Native: A person having origins in any of the original peoples of the Americas and who
maintain cultural identification through tribal affiliations or community recognition.
A = Asian or Pacific Islander: A person having origins in any of the Far East, Southeast Asia, the Indian subcontinent or
the Pacific islands.
B = Black: A person having origins in any of the black racial groups of Africa.
W = White: A person having origins in any of the original peoples of Europe, North Africa, or the Middle East.
Hispanics should be entered with the Race Code most closely representing the individual.

SIGNATURE

DATE

(If you sign this form prior to submitting to Human Resources, it must be notarized.)
NOTARY PUBLIC SIGNATURE:

DATE