Criminal History Consent Form

I hereby authorize Newpoint Partnership Inc to have a records search performed and to receive any criminal history record information pertaining to me which may be in the files of any federal, state or local criminal justice agency.

Full Name: (Please Print) _______________________________________________________

Complete Address: _______________________________________________________

Sex: □ Male □ Female

Date of Birth: _________________________

City/State of Birth: _________________________

Race: _________________________

Social Security Number: _________________________

This authorization is valid for 90 days from date of signature.

Signature: ______________________________________________    Date: _________________