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Local Police Check

Local Police Check

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Published by mpriceatccusa
Local Police Check
Local Police Check

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Published by: mpriceatccusa on May 16, 2013
Copyright:Attribution Non-commercial

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08/26/2014

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LOCAL POLICE CHECK In accordance with agency policy, Catholic Charities is authorized to conduct a policecheck on volunteer mentors. Name:__________________________________________________ Address:_________________________________________________ __________________________________________________ As an adult member of this household, I hereby give my permission for local, county,state police and law enforcement agencies to release to Catholic Charities any and allinformation relating to me. _________________________________________  ______________________ Signature Date
(Please complete all of the following information in full.)
Full Name:_________________________________________ Sex: _______ Birth Date:___________________ Race: ____________________________ Place of Birth:_____________________________________________________ Social Security Number:________________________________________Driver’s License Number:_________________________________________ Maiden Name (if Applicable):__________________________________Former Married Names:__________________________________Any Other Names Used:__________________________________Previous Addresses (if current address is less then 5 years):Street:________________________ Town: ___________________ State: _____ 
FOR POLICE USE BELOW:
 No Record ____________ Record Attached _____________ Other Comments (use back of page if necessary) : _______________________________________________________________________  _______________________________________________________________________  __ 

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