Background Check AuthorizationStart TermFall 2025Fall 2026Fall 2027Fall 2028Fall 2029Spring 2026Spring 2027Spring 2028Spring 2029First NameMiddle NameLast NameFormer NameDate Former Name Used UntilDate Former Name Used UntilJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember123456789101112131415161718192021222324252627282930312000200120022003200420052006200720082009201020112012201320142015201620172018201920202021202220232024202520262027202820292030203120322033203420352036203720382039204020412042204320442045Current AddressCurrent AddressCountryStreetCityRegionPostal CodeCurrent Address SinceCurrent Address SinceJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember123456789101112131415161718192021222324252627282930312000200120022003200420052006200720082009201020112012201320142015201620172018201920202021202220232024202520262027202820292030203120322033203420352036203720382039204020412042204320442045Previous AddressPrevious AddressCountryStreetCityRegionPostal CodePrevious Address FromPrevious Address FromJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember123456789101112131415161718192021222324252627282930312000200120022003200420052006200720082009201020112012201320142015201620172018201920202021202220232024202520262027202820292030203120322033203420352036203720382039204020412042204320442045Social Security NumberBirthdateBirthdateJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember12345678910111213141516171819202122232425262728293031202520242023202220212020201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924192319221921192019191918191719161915191419131912191119101909190819071906190519041903190219011900Phone NumberDrivers License NumberThe information contained in this application is correct to the best of my knowledge. I hereby authorize Alvernia Unversity and its designated agents and representatives to conduct a comprehensive review of my background causing a consumer report and/or an investigative consumer report to be generated for employment and/or volunteer purposes. I understand that the scope of the consumer report/investigative consumer report may include, but is not limited to the following areas: verification of social security number; current and previous residences; and criminal history records from any criminal justice agency in any or all federal, state, county jurisdictions; driving records, birth records, and any other public records.I further authorize any individual, company, firm, corporation, or public agency to divulge any and all information, verbal or written, pertaining to me, to Alvernia University or its agents. I further authorize the complete release of any records or data pertaining to me which the individual, company, firm, corporation, or public agency may have, to include information or data received from other sources.Alvernia University and its designated agents and representatives shall maintain all information received from this authorization in a confidential manner in order to protect the applicant's personal information, including, but not limited to, addresses, social security numbers, and dates of birth.SignatureSignatureBy checking this box, I am verifying that I am the student completing this form and this represents my signature.Notice to California, Minnesota, and Oklahoma Residents Only:Please check the box below if you wish to receive a copy of a consumer report that is requested.Notice to California, Minnesota, and Oklahoma Residents Only:Please check the box below if you wish to receive a copy of a consumer report that is requested.I wish to receive a copy of any Background Check Report on me that is requested.Submit