Background Check Consent: COVID-19 Volunteers

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Background Check Consent Form
I give my permission for the following information to be used by Tri-County Office on Aging to secure information regarding my "conviction only" criminal history. I understand that the information provided below will be kept confidential and used for the sole purpose of checking my criminal history records every five years. Any information obtained by Tri-County Office on Aging will also be kept strictly confidential.
Name*
First Middle Initial Last
Date of Birth*
Date Format: MM slash DD slash YYYY
Sex*
- Male
- Female
Race*
Ethnicity*
- Hispanic or Latino
- NOT Hispanic or Latino
Have you lived outside the state of Michigan in the last 7 years?*
- No
- Yes
If yes, we will contact you for additional information.
Alias names used, including previous married names or maiden name:
Signature*
By typing your name above, you agree that your electronic signature is the legal equivalent of your physical signature.
Date*
Date Format: MM slash DD slash YYYY
Email
This field is for validation purposes and should be left unchanged.

Background Check Consent Form