Criminal Background Check

Consent Form

Your signature below authorizes Lewis & Clark Montessori Charter School and Criminal Information Services, Inc. to obtain information about you (if applicable) from various law enforcement agencies.
Full Legal Name Full Legal Name First Middle Last
Other Names Used
Date of Birth Date of Birth / MM / DD YYYY
Last 4 digits of SS#:
Current Address Current Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Gender

Gender Male Female Other (Please specify) Other (Please specify)
Have you ever been convicted of a crime?

Have you ever been convicted of a crime? Yes No If yes, please explain: If yes, please explain:
I have reviewed and completed this form as applicable to me. I give LCMCS permission to verify any information I have provided. This authorization shall continue to be effective until revoked by me. A digital image, photocopy or facsimile copy of this consent shall be as effective as the orginal. By my signature, I affirm that all information on this form is true and accurate.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Type the letters you see in the image below.