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Release Authorization for an International Background Check
I hereby direct and authorize Plan International USA to conduct a criminal background check on
me and to obtain the results of said background check.
I hereby waive and release any and all manner of actions, causes of actions, and demands of
every kind, nature and description, which I may have now or in the future, arising from any
release of criminal records and requests therefrom, against Plan International USA and its
employees and agents in connection with the criminal background check.
A photocopy of this authorization will have the same authority as the original.

Country of origin:

Print your full name as listed on current passport:

Last

First

Middle

Print other names you have used:

Physical Home Address (not P.O. Box or APO/FPO): City

State

Zip

Code

National identification number:

Date of Birth (For Identification Purposes Only)

Passport number:

Country of issuance:

Sex: □ Male

□ Female

/

Nationality: