Door to Door Solicitation Form

First Name

Middle Name

Last Name

Street Address

City

State/Province

ZIP / Postal Code

Maiden Name or other names used

Date of Birth

Social Security

Have you ever been arrested or convicted for any criminal offenses excluding minor traffic violations?YesNo

Have you ever been accused, arrested, or convicted or abuse or sexually related crimes?YesNo

Is there anything in your life-style or background that would call into question your ability?YesNo

If you have answered yes to any of these questions, please explain

Please note: answering "yes" to any of these questions does not automatically disqualify you. Please use the spaces provided to explain the circumstances.

I hereby authorize... to make an independent investigation of my background and criminal or police records. I release..., and any person or entity which provides information pursuant to this authorization, from any and all liabilities, claims or law suits in regards to the information obtained from any and all of the above sources. The information contained in this application is correct to the best of my knowledge. I understand that any omission of material fact on the application may be grounds for rejection of this application.

Email

Signature

Date

Questions or Comments