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Background Screening Consent and Information Form Please submit this completed and signed form to the Advancement Department attn Carol Nash phone 713-328-5861 email to cnash awty. org or fax to 713-341-4425 Please Print Clearly Last Name First Name MI Please print any other names you have used Email Address Current Address City State Zip Code Phone Number How long have you lived at this address Previous Address I lived at this address from to Month and Year Overseas Address City Country Zip Code Additional Information Date of Birth Social Security Number Driver s License Number State of License Sex Male / Female Circle one Information for International Background Checks Mother s Maiden Name International ID Number Passport Number NCRI Number Foreign Resident ID Other I hereby authorize The Awty International School and/or its agents to make an independent investigation of my background references character past employment education credit history adult criminal or police records and motor vehicle records including those maintained by both public and private organizations and all public records for the purpose of confirming the information contained on my Application and/or obtaining other information which may be material to my qualifications for service now and if applicable during the tenure of my employment or volunteer service with The Awty International School. I release The Awty International School and its agents and any person or entity which provides information pursuant to this authorization from any and all liabilities claims or law suits in regards to the information obtained from any and all of the above referenced sources used. The name above is my true and complete legal name and all information provided above is true and correct to the best of my knowledge Are you applying for employment or a volunteer position in California Minnesota New York or Oklahoma Yes No If so do you want a copy of any Consumer Report prepared concerning you Yes No I understand that California law requires The Awty International School to give me a copy of any report requested within seven 7 days of the date the information was obtained and that failure to do so will expose The Awty International School to liability Section 1786. 29. For Office Use ONLY Signature Date 2011 Praesidium Inc. All rights reserved. Date entered BGC Online Training PW Login delivered Date approved BGC 1 of 1. Background Screening Consent and Information Form Please submit this completed and signed form to the Advancement Department attn Carol Nash phone 713-328-5861 email to cnash awty. org or fax to 713-341-4425 Please Print Clearly Last Name First Name MI Please print any other names you have used Email Address Current Address City State Zip Code Phone Number How long have you lived at this address Previous Address I lived at this address from to Month and Year Overseas Address City Country Zip Code Additional Information Date of Birth Social Security Number Driver s License Number State of License Sex Male / Female Circle one Information for International Background Checks Mother s Maiden Name International ID Number Passport Number NCRI Number Foreign Resident ID Other I hereby authorize The Awty International School and/or its agents to make an independent investigation of my background references character past employment education credit history adult criminal or police records and motor vehicle records including those maintained by both public and private organizations and all public records for the purpose of confirming the information contained on my Application and/or obtaining other information which may be material to my qualifications for service now and if applicable during the tenure of my employment or volunteer service with The Awty International School* I release The Awty International School and its agents and any person or entity which provides information pursuant to this authorization from any and all liabilities claims or law suits in regards to the information obtained from any and all of the above referenced sources used* The name above is my true and complete legal name and all information provided above is true and correct to the best of my knowledge Are you applying for employment or a volunteer position in California Minnesota New York or Oklahoma Yes No If so do you want a copy of any Consumer Report prepared concerning you Yes No I understand that California law requires The Awty International School to give me a copy of any report requested within seven 7 days of the date the information was obtained and that failure to do so will expose The Awty International School to liability Section 1786.