Background Check Release Form

SAMARITAN SERVICES 
111 Wood Street Englewood NJ 07631 
NOTICE OF BACKGROUND CHECK 
[IMPORTANT -- PLEASE READ CAREFULLY BEFORE SIGNING BELOW]

Note: Conducting a Social Security Trace does not access the subject's credit history nor affects the subject's credit score or credit rating. Please note that by signing below you are authorizing and instructing an immediate criminal background and driving record reports from a third party (utilizing a Social Security Number trace) as deemed necessary and appropriate. Moreover, you are allowing reports from a third party on an ongoing basis without any additional notice for as long as you are a member.

AUTHORIZATION AND INSTRUCTION 
I acknowledge receipt of the NOTICE OF BACKGROUND CHECK and certify that I have read and understand that notice. I hereby authorize and instruct

Print Name *

to obtain criminal background and/or driving record reports from a id party (utilizing a Social. Security Number trace) as deemed necessary and appropriate. This authorization and instruction will take immediate effect when I sign below, and will last throughout the duration of my involvement as a volunteer member. Accordingly, you may obtain additions I criminal background and/or driving record reports from a third party on an ongoing basis throughout my association with your organization without any further notice or additional warning. To this end, I hereby authorize without reservation any law enforcement agency, administrator, local, state or federal agency, info nation service bureau and/or the Social Security Administration to furnish any and all background information (including criminal history and/or driving records and not credit history) requested by Backgroundchecks.com, another outside organization acting on your behalf. I agree that a facsimile ("fax") or photographic copy of this Authorization and Instruction shall be as valid as the original.

Include a legible photo copy of your Driver's License attached to this document *

Maximum upload size: 2.1MB

Printed Name *

Social Security Number *

Driver's License # & State *

Date *

Date of Birth *

Signature *

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Background Check Release Form

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