Name Based Criminal History Record Information Consent/Inquiry Form
I hereby give consent for Pleasant Hill Baptist Church to conduct an inquiry and receive any Georgia criminal history
record information pertaining to me, which may be contained in the files of any state or local criminal justice agency in
Georgia.
Full Name (Print) _______________________________________________________________________________
Address: ______________________________________________________________________________________
Sex: __________ Race: ___________ Date of Birth: ____________________ SSN#: _______________________
This authorization is valid for 180 days from the date of signature.
I, _____________________________________ give consent to the above named to perform periodic criminal history
background checks for the duration of my employment with this company.
________________________________________________ _______________________
Signature Date
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -- - - FOR OFFICE USE - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Date of Inquiry: ____________________ Time of Inquiry: _________________ Operators Initials: _____________
Please check which applies.
_______ Employment (E) - Provides Georgia Criminal History Record Information
_______ Employment win Mentally Disabled (M) - Provides Georgia Criminal History Record Information
_______ Employment with Elder Care (N) - Provides Georgia Criminal History Record Information
___X___ Employment with Children (W) - Provides Georgia Criminal History Record Information
_______ Public Records (P) - Provides Georgia Criminal History Record Information
Agency Name Requesting Information: _______________________________________________________
Agency Phone Number: ___________________________________________________________________
Agency Designee Signature and Title: ________________________________________________________
The inquiry resulted in the following: (Check all that apply)
__________ No Georgia CHRI results available.
___________________________________ __________________________________ ________________
Released To: Released By: Date
__________ Georgia CHRI attached/released
___________________________________ __________________________________ ________________
Released To: Released By: Date
