Background Check Consent

  • 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.
  • Date Format: MM slash DD slash YYYY
    If yes, we will contact you for additional information.
  • By typing your name above, you agree that your electronic signature is the legal equivalent of your physical signature.
  • Date Format: MM slash DD slash YYYY
  • This field is for validation purposes and should be left unchanged.