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REPORT ANIMAL CRUELTY
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BACKGROUND CHECK AUTHORIZATION
Print Name:
*
Former Name(s) and Dates Used:
*
Current Address Since:
*
Line 1
Line 2
City
State
Zip Code
Country
Previous Address From:
*
Line 1
Line 2
City
State
Zip Code
Country
Previous Address From:
*
Line 1
Line 2
City
State
Zip Code
Country
Social Security Number:
*
DOB:
*
Mo/Day/Yr
Telephone Number(s):
Work
*
Mobile:
*
Home:
*
Driver’s License Number:
*
State:
*
The information contained in this application is correct to the best of my knowledge.
I hereby authorize Minnesota Federated Humane Societies 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; credit reports, current and previous residences; employment history, education background, character references; drug testing, civil 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 Minnesota Federated Humane Societies 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. Minnesota Federated Humane Societies 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.
Signature:
*
Max file size: 20MB
Date:
*
Submit
Home
REPORT ANIMAL CRUELTY
How to Report Animal Cruelty
>
MFHS Online Report Form
RESOURCES
State and Federal Animal Welfare Laws
Pet Resources
Wildlife Resources
Veterinarian Resources
Educational Resources
Community Cats, Affordable Veterinary Resources & Participating Rescues
>
Participating Cat Rescues
Minnesota Humane Societies, Shelters & Rescues
MFHS Team Members
Donate
Wish List
Fundraising Campaigns
Employer Giving
Estate & Planned Giving
Contact Us
ABOUT
Our Story and Mission
Success Stories
Legislation
Volunteer/Employment Opportunities
Volunteer Opportunities
GET INVOLVED, BECOME A STATE HUMANE AGENT
>
State Humane Agents
Become a State Humane Agent
Training
DONATE