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					           NATIONAL SEX OFFENDER REGISTRY CHECK


I hereby authorize the Washington Conservation Corps (WCC) to conduct a sex offender registry
check, using the information provided below, on the Department of Justice National Sex
Offender Registry, www.nsorp.gov.

I acknowledge that in order to participate in the WCC program this sex offender registry check
must be conducted in order to comply with the AmeriCorps subgrantee rules as set forth by the
Corporation for National & Community Service.

I understand that the information obtained during the sex offender registry check will be solely
for the purpose of determining my eligibility to participate in the WCC program and will remain
confidential.

I understand that if I am subject to a state sex offender registration requirement, I am deemed
unsuitable for and may not serve in an AmeriCorps program, according to the AmeriCorps
subgrantee rules as set forth by the Corporation for National & Community Service.

However, before such determination is made, I will have the opportunity to review and challenge
the factual accuracy of a sex offender registry check result.


______________________________________________                          _______________________
Signature of AmeriCorps applicant                                       Date



First Name __________________________________ MI: ________

Last Name __________________________________

Date of Birth ________________________________

City ____________________________            State______________

County__________________________             Zip Code __________

*If residency at above address is less than one year, please list previous address:

City ____________________________            State______________

County__________________________             Zip Code __________




                                                                         Background Check Page 1
           AUTHORIZATION FOR BACKGROUND CHECK


I hereby authorize the Washington Conservation Corps (WCC) to conduct a criminal background
check, using the information provided below.

I acknowledge that in order to participate in the WCC program this criminal background check
must be conducted in order to comply with the AmeriCorps subgrantee rules as set forth by the
Corporation for National & Community Service.

I understand that the information obtained during the criminal background check will be solely
for the purpose of determining my eligibility to participate in the WCC program and will remain
confidential.

I understand that if I am subject to a state criminal offense, I may be deemed unsuitable for and
may not serve in an AmeriCorps program, according to the AmeriCorps subgrantee rules as set
forth by the Corporation for National & Community Service.

However, before such determination is made, I will have the opportunity to review and challenge
the factual accuracy of the criminal background check result.


______________________________________________                         _______________________
Signature of AmeriCorps applicant                                      Date


First Name __________________________________

Last Name __________________________________

Date of Birth ________________________________

Gender (circle):   Female            Male

City ____________________________           State______________

County__________________________            Zip Code __________

*If residency at above address is less than one year, please list previous address:

City ____________________________           State ______________

County __________________________           Zip Code __________




                                                                        Background Check Page 2

				
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