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Background Check Consent and Release

Personal Information
Previous Names Used
Current Address
Address History
If less than five (5) years at current address, provide previous address(es).
From MM/YYYY
To MM/YYYY
Street
City
State
Zip
 
Contact Info
Email Address
Cell Phone
Home Phone
 
Personal Info
Date of Birth
Social Security #
Driver License #
State Issued
 
*NOTE: The above information is required for identification purposes only, and is in no manner used as qualification for employment.
Have you ever applied to LCCS before?
Have you ever applied to LCCS before?
If so, when?
If so, when?
 
Are you a former employee or alumni?
Are you a former employee or alumni?
Background Investigation Consent
Release
Background Investigation Consent and Release(Required)
Applicant's Complete Legal Name (Print)
Applicant's Signature or Electronic Signature
Date