Criminal background form .pdf
Original filename: Criminal background form.pdf
Title: DOUGLAS COUNTY SCHOOL SYSTEM
Author: Preferred Customer
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DOUGLAS COUNTY SHERIFF’S OFFICE
6840 WEST CHURCH STREET
DOUGLASVILLE, GA 30134
CRIMINAL BACKGROUND CHECK CONSENT FORM
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:
DATE OF BIRTH
SOCIAL SECURITY NUMBER
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.
(If you sign this form prior to submitting to Human Resources, it must be notarized.)
NOTARY PUBLIC SIGNATURE:
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