UPATX Background Check 
Volunteer/Host Family Background Check Authorization
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Name( (Last, Full First, MI, & Maiden Name, if applicable) *
Birthdate: (MM/DD/YYYY) *
Provide home addresses for the past three years, most recent first: 
Street, Apt # City, State,  Zip, County
 *
Phone Number *
Email *
I am completing this form as a *
I understand that my continued service with the Ulster Project Arlington is conditional, pending the satisfactory completion of a criminal background investigation. 
With this form submission, I authorize Ulster Project Arlington to conduct a criminal background check and abuse registry check for the purpose of my continued service as a volunteer. I hereby authorize law enforcement agencies, administrators, state agencies and other public or private entities which may possess the above mentioned information to furnish such information to the Ulster Project or its agent. I hereby release the Ulster Project, its agents, and all persons providing information or reports about me, from any and all liability arising of the request for or release of any of the above mentioned information or reports. 
 *
Required
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.  *
Date of Signature *
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