Free background check form 12
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Name-Based Criminal Background History Record Information Consent/Inquiry Form
I hereby authorize

Alto Police Department

to conduct an inquiry for

Agency/Company

Accurate Background
(company) with the purpose(s) listed below and receive any Georgia
and/or national criminal background history record information as authorized by state and federal law.
Full Name (print)
AKA name(s)
Address
Sex

Race

Date of Birth

This authorization is valid for

90

Social Security Number

days from 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 that apply)
E - Employment
N - Working with Elderly
W - Working with Children

Official use only:
Inquiry:

Time of Inquiry:

Operator’s Initials:

The inquiry resulted in the following: (check all that apply)
No Criminal Record Available
Criminal Record (Attached/Released)
No NCIC/GCIC Warrant
Possi