HTML Preview Background Check Authorization And Release Form page number 1.
Authorization for Release of Information
Basic Background Check
(05.061-F2)
Full Legal Name:
Last Name First Name Middle Name
Other Names / Nickname(s) / Also Known As:
Date of Birth:
Month Day Year
Do you have a current Drivers License? Yes No Driver Lic. number? __________________
Which State issued? __________________
I authorize Clark Regional Emergency Services Agency (CRESA) and/or the Clark County Sheriff’s Office on
behalf of CRESA to run a basic background check for any current wants or warrants by law enforcement
agencies.
• I understand that any information obtained by this background check will be considered in determining
by suitability for employment by or volunteer service for Clark Regional Emergency Services Agency.
• I understand that falsification, misrepresentation or omission of any facts pertaining to this background
check will be cause for denial of employment and/or volunteer service or for immediate termination of
employment and/or volunteer service regardless of the timing and circumstances of discovery.
• I understand that unsatisfactory result from, refusal to cooperate with, or any attempt to affect the
results of the background check will result in withdrawal of any offer of employment and/or volunteer
service or termination of employment or service.
• I understand that if contradictory results are found, additional information may be requested of me to
help verify and ascertain identity and/or validity of the background check results.
This release will be valid for up to one month from the date of applicant’s signature below. A photocopy of this
release form will be valid as an original, even though the said photocopy does not contain an original writing of
my signature.
Applicant Signature: __________________________________ Date: ________________________
Office use only:
1. Division Contact – Complete section below and forward signed basic background to On-Duty Dispatch Supervisor for processing.
Division Contact Name:
Date Requested:
CRESA Division: 911 Dispatch Admin Emer Mgmt / EOC EMS Tech Svcs
2. On-duty Dispatch Supervisor – Run name(s) to determine current wants or warrants. Complete documentation below. Forward completed results
back to Division Contact.
Check Conducted by (PSN): Date Check Conducted:
Wants & Warrants Results: Clear (wants & warrants) Not Clear (wants & warrants)
Incorrect / Insufficient information to run: (comments)
3. Division Contact – After logging results, forward original form and results to Human Resources, for filing.