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5303 South Cedar,
Lansing
, MI
48911
517-887-1440
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Background Check Consent: COVID-19 Volunteers
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Background Check Consent: COVID-19 Volunteers
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.
Name
*
First
Middle Initial
Last
Date of Birth
*
Date Format: MM slash DD slash YYYY
Sex
*
Male
Female
Race
*
White
Black
Asian or Pacific Islander
American Indian or Alaskan Native
Unknown or Other
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.
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