APPLICANT REQUEST –
CHOOSE ONLY ONE
USE THIS FORM FOR:
• CO-SPONSORED COACHES
• FIRE/EMS VOLUNTEERS
• COUNTY EMPLOYMENT
•
PROSPECTIVE COUNTY EMPLOYEES
• SOCIAL SERVICE APPLICANTS
• COUNTY VOLUNTEERS
• SOLICITOR/PERMITS
APPLICANT
’
S PERSONAL INFORMATION
Last Name
(With Suffix)
First Name
Full Middle Name
Other Legal Names Used
Maiden Name
Gender
Male
Female
Race
Height
‘Feet ‘’Inches
Weight Pounds
Social Security Number
Eye Co
l
or
Hair Color
Date of Birth
State of Birth
COUNTRY
OF BIRTH
Street Address
City, State & Zip Code
Home Telephone
Work Telephone
Cellular Telephone
AUTHORIZATION TO OBTAIN BACKGROUND INFORMATION
I, the applicant, hereby authorize Chesterfield County to obtain records related to me, if any, from criminal justice
agencies. I understand that the information
released is for “OFFICIAL USE” by Chesterfield County for the sole
purpose of determining my eligibility to: volunteer, be employed, be promoted or transferred, or for Social Services
application and may be disclosed to other persons only as necessary to determine my eligibility. I understand that
failure to provide all or part of the information may result in my disqualification for volunteerism, employment and
or application considerations with Social Services. This release shall be effective on the date of its execution and
will expire upon completion of my criminal record check.
Today’s Date
Applicant’s Signature
Do Not Write or Mark In The Area Below
PD75F Rev 07/2019
Proving a FIRST CHOICE Community through Excellence in Public Service
TCN:
CONTROL NUMBER
Co-Sponsored League
Or Association
Coaches Card Renewal:
(Current Card Number)
F IR E / EM S VOLUNTEER
Fire
Station # or Rescue Squad
C O U N T Y E M P L O YM EN T
Employee: Position or Promotion
Social Services
Request
Other: Please Specify
click to sign
signature
click to edit
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