Criminal Background Check Form

Applicant: Complete this form if you do not reside in Kentucky all year, or if you have lived in Kentucky less than seven years.

National Background Investigations, Inc.
Post Office Box 156
Mayo, Maryland 21106
Tel: 410-798-0072 / 800-798-0079
Fax: 410-798-7868 / 800-798-7895

Applicant Release and Authorization Form

I hereby authorize Girl Scouts of Kentuckiana or other authorized representatives of the organization bearing this release, or copy thereof, to obtain any information pertaining to any of the following: my employment history, military record, credit profile, criminal history record, driving record, or educational records. I herby direct you to release such information upon request of Girl Scouts of Kentuckiana or other authorized representatives of the organization.

I herby fully release and discharge my prospective employer or other authorized representatives of the organization, their respective affiliates, employees, agents, attorneys and any individual organization, entity, agency or other source providing information to my prospective employer from all claims and damages arising out of or relating to any investigations of my background for employment purposes. I acknowledge that a telephonic facsimile or photographic copy shall be valid as the original.

Please Provide Minimum 7 Years of Residential History Below

Name (First, Middle, Last):
Other/Alias:
Date of Birth:
Driver's Lic. No.:
State:

Current Address:
City/State:
County:
Dates: From: To:

Previous Address:
City/State:
County:
Dates: From: To:

Please review all data before submitting.