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Anyone over the age of 18 must have a background check run in by 4t1kE0o

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									Request For Criminal Records Check and Authorization


I hereby request the Oklahoma State Bureau of Investigation (OBSI) to release any
information, which pertains to any record of convictions contained in its file maintained
on me whether local, state, or national. I hereby release Community Action Ministries,
Inc. (CAM) from any and all liability resulting from such disclosure.




Signature


________________________________________________________________________
Print First, Middle, and Last Name


________________________________________________________________________
Print maiden name if applicant


________________________________________________________________________
Print all aliases, including all married names


________________________________________________________________________
Date of Birth


Social Security Number


________________________________________________________________________
Drivers license number


Today’s Date



Background check completed: Date: ____/____/____ clear record _____yes ____no

								
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