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EAU CLAIRE COUNTY SHERIFF’S OFFICE
BACKGROUND CHECK AUTHORIZATION
NAME OF PERSON MAKING THE REQUEST (PLEASE PRINT):
(FIRST)
(MIDDLE)
Telephone Numbers: (Home):
(LAST)
(Cell):
(Other):
Driver’s License Number:
State:
Email Address:
NAME OF PERSON YOU WANT A BACKGROUND ON (PLEASE PRINT):
(FIRST)
(MIDDLE)
(LAST)
Date of Birth:
Former Name(s) Used:
Current Address Since:
(Mo/Yr)
(Street)
(City)
(State/Zip)
(Mo/Yr)
(Street)
(City)
(State/Zip)
Previous Address Since:
_
Telephone Numbers: (Home):
(Cell):
(Other):
Driver’s License Number:
State:
The information contained in this application is correct to the best of my knowledge. I hereby authorize Eau Claire County
Sheriff’s Office and its designated agents and representatives to conduct a comprehensive review of my background.
I further authorize Eau Claire County Sheriff’s Office to divulge any, and all information, verbal or written pertaining to me to
or its agents. I further authorize the complete release of