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Background Check Release Form
Please type your answers.
FULL LEGAL NAME ____________________________________________________________________________
(Last)
(First)
(Middle)
(Maiden)
SSN ___________ - _______ - _________
DATE OF BIRTH _________ / _________ / __________
(Mo)
(Day)
(Year)
RACE _____________________
HOME PHONE ( _____ ) ______ - _________________
SEX _________
HOME ADDRESS ______________________________________________________________________________
(Street)
__________________________________ _________________ ________________________________________
(City)
(State)
(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