Putnam County Youth Development Commission
Authorization to Perform Criminal Record Check
I, _______________________________ hereby authorize the Putnam County
Youth Development Commission to perform a criminal record check on my behalf
in any and all states in which I have resided in the last ten (10) years.
I am aware that the criminal record check is a mandatory requirement for
employment or volunteer service at the Putnam County Youth Development
Commission; and that any records of felony criminal convictions, or any
convictions involving minors may prevent me from being eligible to work or
volunteer with the Putnam County Youth Development Commission.
_________________________________ ____________________
Signature of Application Date
Address:_________________________________
___________________________________
Date of Birth:______________________________
Social Security #:___________________________