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					                                              Midland County
                               Prospective Employee Background Check

I hereby authorize the Midland County to perform a criminal history background check while I
am being considered for possible employment with Midland County. I understand there is no fee
associated for this investigation and that the information will be kept strictly confidential to
Midland County.

   Full Name

   Street Address
   City, State Zip

   Date of Birth

   Social Security Number

   Drivers License Number

       Prospective Employee Signature                                   Date

 Elected Official/Department Head Signature                             Date

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