Georgia Bureau of Investigation

Georgia Crime Information Center Consent Form

I hereby authorize Protect My Ministry to conduct an inquiry for the purpose below and receive any Georgia and/or national CHRI as authorized by state and federal law. This is a criminal background release. *

YES

NO

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Sex *

Female

Male

PREFER NOT TO ANSWER

Race *

Date of Birth * +

Social Security Number *

I, the below signed, give consent to the above-named entity to perform periodic criminal history background checks for the duration of my employment. *

clear

Date * +

Purpose Code Used (check only one): *

Organization/Employer Name *