Volunteer Application Broward County Page 3
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4BROWARD COUNTY BOARD OF COUNTY COMMISSIONERS
Finance and Administrative Services Department
Risk Management Division | Safety & Occupational Health Section
ACKNOWLEDGEMENT, AUTHORIZATION AND REQUEST
INSTRUCTIONS
FOR CRIMINAL BACKGROUND INFORMATION
ACKNOWLEDGMENT AND AUTHORIZATION FOR BACKGROUND CHECK AND RECORD RELEASE
Check appropriate box for: Employment, Volunteer or Community Service Worker
Intern
Volunteer
Community Service Worker (court ordered)
I acknowledge receipt of the separate documents entitled BACKGROUND INVESTIGATION DISCLOSURE and A SUMMARY OF
YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT, and certify that I have read and understand both of the documents. I
hereby authorize the obtaining of “consumer reports” and/or “investigative consumer reports” by Broward County at any time after receipt
of this Authorization and throughout my employment or period of volunteer service, if applicable. To this end, I hereby authorize, without
reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private),
information service bureau, employer, or insurance company to furnish any and all background information requested. These searches
will be conducted by Edge Information Management, Incorporated, 1682 W. Hibiscus Blvd., Melbourne, Florida 32901,
1-800-725-3343, and/or American Prestige Screening, P.O. Box 550674, Atlanta, GA 30355; Telephone
(888) 943-8985, and/or Broward County, itself. I agree that a facsimile (“fax”), electronic or photographic copy of this Authorization shall
be as valid as the original.
PERSONAL INFORMATION – ALL SPACES MUST BE COMPLETED
First
Middle
Last
Name: ________________________
Name: _______________
Name: __________________________________ Suffix: ______
Other Prior Names/Maiden Names/Aliases: _________________________________________________________________________
DOB: _________ / __________ / _____________
Gender:
Male
Female
_________
_______
__________
mm
dd
yyyy
Social Security Number
Race: (Check One)
White-Not Hispanic
Black-Not Hispanic
Hispanic
Asian/Pacific Island
American Indian/Alaskan Native
Current Address: ______________________________________________________________________________________________
How long have you lived in Florida? _________
_________ Driver’s License: _____________________
____
_____________
Years
Months
License Number
State
Expiration Date
Previous Addresses: ___________________________________________________________________________________________
Out of the state of Florida. Must be completed if you have lived in Florida for less than 10 years.
CRIMINAL RECORD (if any)
Since your 18th birthday, have you been convicted of or entered a plea of guilty or nolo contendre (no contest) to any violations of law.
You must include all felonies and misdemeanors, other than non-criminal traffic offenses, even if adjudication was withheld?
Yes
No If yes, please provide the following information: (use a separate sheet of paper if multiple records exist)
Offense: __________________________________________________________________________
Misdemeanor
Felony
Name & Location of court: ______________________________________________________________________________________
Court Disposition: ___________________________________________________________________
Date: ___________________
Note: A conviction does not automatically disqualify you. The nature of the offense, how long ago it occurred, relationship to your duties and agency assigned, etc. will be given consideration.
Printed Name: _______________________________________________________________________________________________
_________________________________________________________________
Date: ____________________________
SIGN ►
Candidate/Volunteer Signature
ACKNOWLEDGEMENT/AUTHORIZATION BACKGROUND REQ FORM (Rev. November 2015)
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