Criminal Record Check Authoriza on Form

In September of 2009, the Corpora on for Na onal & Community Service (CNCS) has issued a new regula on
that all new AmeriCorps members enrolled on or a er October 1, 2009 will need to have a criminal record
check completed and reviewed by the Vet Corps program before a member can be officially enrolled.

Member Completes:
Full Legal Name: _____________________________________________________________

All Names Used (to include Maiden Name):

__________________________________________________________________________

Permanent Home Address: ____________________________________________________

City, State, Zip: ______________________________________________________________

Social Security Number: ______________________Date of Birth: _____________________

In connec on with my service with AmeriCorps and par cipa on in the Vet Corps Program, I hereby authorize
the Vet Corps program to conduct a criminal background check on my behalf. I understand that this check will
cover a search of law enforcement and court records and a check of the Na onal Sex Offender Public Registry.
Background checks will be done through Washington State Patrol WATCH. I understand that my ability to serve
as a Vet Corps Member is con ngent upon the results of the background check. I understand that failure on
my part to consent to the review will result in the cancella on of my enrollment in the Vet Corps Program.
Results are confiden al, but may be shared with the Vet Corps Program Manager if necessary. The member is
en tled to receive and review the informa on obtained, upon wri en request. I cer fy that statements made
by me on this form and in my enrollment paperwork are true, complete, and correct to the best of my
knowledge and belief, and are made in good faith. I understand that any false statements made herein could
void my eligibility to serve with the Vet Corps Program.

Member Signature: ______________________________________Date: ________________

Created June 2012/Revised June 2018 Page 1 of 1