Fillable Authorization for Criminal Background Check

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Authorization for Criminal Background Check

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The Authorization for Criminal Background Check form is 1 page long and contains:

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  • 2 check-boxes
  • 11 other fields

Country of origin: OTHERS
File type: PDF

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_______ Money Order
_______________Date Received
___________ Processed By?
Authorization for Criminal Background Check
By filling out the following information, I am authorizing the SC Respite Coalition to process my
criminal background check through the SC Law Enforcement Division (SLED).
Name: Last ______________________________ First _______________________ MI ______
Maiden or other names I have used: ____________________________________________________
__________________________________________________________________________________
Social Security Number: __________________________________
Gender (Male/Female): _________________
Date of Birth: __________________________________________
Signature: ______________________________________________ Date: _________________
If only SLED check is required please make payment of $12.00.
If you require both SLED and DSS you can pay a combined fee of $24.
____ I have already paid on-line ____ I will pay on-line.
____ I have enclosed a money order for $12 made payable to the SC Respite Coalition.
____ I have enclosed a money order for $24 and included my DSS forms.
_______ Online Payment
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Authorization for Criminal Background Check

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Completed 21 November 2021

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