WASHINGTON COUNTY HOUSING AUTHORITY

AUTHORIZATION FOR CRIMINAL RECORD

I, , do hereby authorize the Washington County Housing Authority to access/obtain, from any person, agency or service, regarding my background which may assist in determining whether I have a criminal history.

I understand that this information will be used to determine my eligibility for public housing. I understand that signing this authorization in no way guarantees my eligibility for public housing.

All adults age 18 years and over must complete this form.

FULL NAME:

ANY ALIAS NAMES:

DATE OF BIRTH:

ANY ALIAS DATES OF BIRTH:

SOCIAL SECURITY NUMBER:

ANY ALIAS SOCIAL SEC. #'S:

CURRENT ADDRESS:

PREVIOUS ADDRESS:

Signed: Printed:

Date:

Washington County Housing Authority© Copyright 2002-2003, Melissa McClure
Last revised: May 17, 2003 .