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AUTHORIZATION FOR RECORD CHECK

Position(s) Desired:

PLEASE PRINT FULL NAME CLEARLY (Including Middle Name)

Name: [esigninja formid="46" field_id="1356" display="value" ] [esigninja formid="46" field_id="1359" display="value" ] [esigninja formid="46" field_id="1361" display="value" ]
Maiden/Previous Name(s): [esigninja formid="46" field_id="1363" display="value" ]
Social Security #: [esigninja formid="46" field_id="1372" display="value" ] Date of Birth: [esigninja formid="46" field_id="1370" display="value" ]
Current Address: [esigninja formid="46" field_id="1358" display="value" ]
City: [esigninja formid="46" field_id="1360" display="value" ] State: [esigninja formid="46" field_id="1362" display="value" ] Zip Code: [esigninja formid="46" field_id="1364" display="value" ]

Previous Address (If less than four years at current address) [esigninja formid="46" field_id="1379" display="value" ]
Driver’s License: # [esigninja formid="46" field_id="1374" display="value" ] Exp Date: [esigninja formid="46" field_id="1377" display="value" ]

Contact Number: [esigninja formid="46" field_id="1365" display="value" ] Email Address: [esigninja formid="46" field_id="1367" display="value" ]
I, [esigninja formid="46" field_id="1356" display="value" ] [esigninja formid="46" field_id="1361" display="value" ], do hereby authorize the Louisville Urban League to search any police record(s) for any arrest, conviction(s) or information they may have regarding me, and to make this information available to the Louisville Urban League. I do understand that, depending on program policies and requirements, previous or current information regarding me may be needed. I agree that a photocopy of the authorization may be used for the purposes stated above. The original of this authorization is on file with the Louisville Urban League and will stay in effect for a year and one month from the date signed.

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March 25, 2020 11:40 pm EDT

LUL AUTHORIZATION FOR RECORD CHECK Uploaded by Lyndon Pryor - [email protected] IP 99.53.73.239