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Background Check

* indicates a required answer.

NOTE: Only one free background check per family. Additional family members background checks are $12 per person.

To ensure your privacy, the application information is kept confidential.

1.*

Please check here if you are a:


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2. *

Full Name (First, Middle, Last Name)

3. *

Maiden name/Aliases (if applicable)

4. *

Date of Birth

5. *

Address with City, State, Zip

6. *

Email Address

The following are my response to questions about my criminal history (if any):

7.*
Have you ever been convicted or plead guilty before a court for any federal, state or municipal
criminal offense? (Excluding minor traffic misdemeanors).
8.*
Have you ever been charged with any criminal offense that will show up on your criminal
background check?
This authorization and consent acknowledges that HPHE may conduct a national criminal background check and a National Sex Offender Registry search. I authorize and consent for full release of my criminal records and any record of my name being listed on the National Sex Offender Registry (either orally or in writing) to the authorized representatives of HPHE. In addition, I release and discharge HPHE and its agent to the full extent permitted by law from any claims, damages, losses, liabilities, costs, expenses or any other charge or complaint filed with any agency arising from retrieving and reporting this information. After reading this document, I fully understand its contents and authorize the background verification. I have read the above statement, and I am signing this release as my own free act.
9. *

Signature

10. *

Date