City of Crockett Police Department Personal History Statement
CPD 05/08/2014 2
Background Waiver Applicants Full Name: ________________________________________________________ Date of Birth: _____________
______ Driver’s License Numb
er: ____________ State: ___ Social Security Number: _______________________________________________________ Current Address: ____________________________________________________________ Home Phone Number: __________________ Cell Phone Number: ___________________ Email Address: ______________________________________________________________
I, _________________________________________, hereby authorize, by signing my initials, the following:
I authorize the Crockett Police Department to contact any and all previous employers, references, family members and any other person listed on my application for the purposes of conducting a background check for employment.
I further authorize all previous employers, references, family members and any other persons listed on my application to release any and all information on me to the Crockett Police Department for the purposes of my background check for employment.
I also authorize the Crockett Police Department to run a computerized criminal history on me for the purposes of a background check for employment with their agency.
Applicant’s Signature: ____________________________________________
Date: ___________________________ Time: ______________________