Free background check form 28Free background check form 28Free background check form 28
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Background Check Release Form

Please type your answers.
FULL LEGAL NAME ____________________________________________________________________________
SSN ___________ – _______ – _________

DATE OF BIRTH _________ / _________ / __________

RACE _____________________

HOME PHONE ( _____ ) ______ – _________________

SEX _________

HOME ADDRESS ______________________________________________________________________________
__________________________________ _________________ ________________________________________
(Zip Code)
COUNTY OF RESIDENCE ______________________________________________________________________
I respectfully request and authorize the release to the Mississippi Joint Legislative PEER Committee from any law enforcement
agency; federal or state agency, governing authority, municipality and/or county; private employer or business entity; bank or financial
institution; college or educational institu