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STATE OF MAINE
DEPARTMENT OF HEALTH AND HUMAN SERVICES

Maine Background Check Center
Notification and Authorization and Release
Driver’s License # and State of Issue/Passport Number:

Date of Birth:

Applicant / Employee Full Legal Name: (First, Middle, Last)

List all Aliases/Maiden Names:

Address:

Phone number:
Position(s) Applied for:
Occupational or Professional Licensing Identification Numbers and Type (if applicable) and State of Issue:

Notice to the Applicant / Employee
This organization has offered you a position contingent upon a clear background check. The organization requires you to
consent to the comprehensive background check. Your eligibility to work in this position is dependent upon whether you
have a disqualifying offense in your background.
You must authorize a release of information relevant to your background, including your criminal history records and any
substantiation for child or adult abuse. This information will be sent to the Maine Background Check Cent