WARREN CONSOLIDATED SCHOOLS

HUMAN RESOURCES DEPARTMENT

BACKGROUND CHECK AUTHORIZATION FORM

It is the policy of Warren Consolidated Schools to secure criminal conviction history information as mandated by Michigan state law for public school employees and volunteers.

If this information is being requested for a volunteer, list the building asking for the information. Background check forms must be submitted two weeks prior to trip or event.

Building:

Date of Trip:

NAME ____________________________________________________________

LAST FIRST MIDDLE

Maiden Name/Names previously used ________________________________________

Date of Birth _____________________________Gender_____________________________

Driver’s License Number _____________________________________

Please attach a photo copy of your Driver’s License or State ID Card.

I understand that the above information is required by the Central Records division of the Michigan State Police, Lansing, Michigan. I authorize Warren Consolidated Schools to utilize the above information for the sole purpose of obtaining a conviction only criminal history file search.

__________________________________________ ________________________

SIGNATURE OF APPLICANT DATE

06/19/07