Background informed consent

Background informed consent
Email

Date

The following individual has made application with this agency for the following position

Last name of applicant

First name

Middle

Maiden, alias or former

Date of birth

Gender

Male

Female

Social security number

I authorize the Minnesota Bureau of Criminal Apprehension to disclose all criminal history record information to the Hennepin County Medical Examiner’s Office for the purpose of employment with this agency.

The expiration of this authorization shall be for a period no longer than one year from the date of my signature.

Signature of applicant

Some specific browsers or devices may not work properly with the signature field. If you have issues, please try another device.

Date signed

Check if you would like a copy sent to you by email

Please confirm your email address