LOCAL POLICE CHECK

In accordance with agency policy, Catholic Charities is authorized to conduct a police
check 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 all
information 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) :
_______________________________________________________________________
_______________________________________________________________________
__

_________________________
______________________________
____________
Name
Signature
Date
Position: ________________________ Police Dept./Agency: _____________________

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