Burrillville Parks & Recreation Department
105 Harrisville Main Street
Harrisville, RI 02830
RECORD CHECK REQUEST
APPLICANT INFORMATION (please print clearly)
Last Name: ______________________________ First:_____________________ MI:______
Any alias names used/including maiden:________________________________________
Date of Birth:______________________ Social Security #:_________________________
Address:___________________________________________________________________
All states in which you have lived as an adult:_______________________________-----__
Drivers License Number: _____________________ State of Issue:_______________
Criminal Record Check Disclaimer: I, ____________________________, certify that the above information is accurate. Also, having applied or volunteered for an organization that falls under the BURRILLVILLE PARKS & RECREATION DEPARTMENT, I understand that a criminal record check will be performed. Therefore, I authorize this Police Department to run a criminal history check on me in each of the states listed above. I further authorize disclosure of any record found to THE BURRILLVILLE PARKS & RECREATION DEPARTMENT. Please return any information in the enclosed self-addressed stamped envelope.
______________________________________________________________________
signature of applicant date
Notarized by: ________________________________________ Date:______________
My commission expires on ______________________________
Notarization is required to be completed before submission.
POLICE DEPARTMENT FINDINGS:
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