"Background Check Authorization Form" - Georgia (United States)

Background Check Authorization Form is a legal document that was released by the Georgia Department of Banking and Finance - a government authority operating within Georgia (United States).

Form Details:

  • Released on March 1, 2014;
  • The latest edition currently provided by the Georgia Department of Banking and Finance;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Georgia Department of Banking and Finance.

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Download "Background Check Authorization Form" - Georgia (United States)

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Complete Applicant Name (First, Middle, Last)
Name of Entity (Existing or Proposed)
BACKGROUND CHECK AUTHORIZATION FORM
TO WHOM IT MAY CONCERN:
I hereby authorize the Department of Banking and Finance (Department) to obtain criminal history data on the undersigned in his/her
capacity as a director, officer, principal, owner, policymaker, manager or employee of the above entity. I understand this will be a FBI
criminal background check. Also, pursuant to Section 7-9-7 of the Official Code of Georgia Annotated and the Rules of the Department
of Banking and Finance, the Department is authorized to obtain information regarding character, ethical reputation and financial
responsibility. Such information and any conviction data received by the Department shall be used by the Department for the exclusive
purpose of carrying out the responsibilities of this article, shall not be a public record, shall be privileged, and shall not be disclosed to
another person or agency except to any person or agency which otherwise has a legal right to inspect the file. In order to facilitate this
inquiry, I understand that I must provide the information below. The Department will notify me if further information is required. Should
the data show that a violation of the Georgia Merchant Acquirer Limited Purpose Bank Act and/or the Rules of the Department of
Banking and Finance exists, I understand that the Department may take the appropriate administrative action against me and/or the
affiliated entity. The procedures for changing, correcting, or updating a criminal history record is set forth in Title 28, Code of Federal
Regulations (CFR), Section 16.30 through 16.34.
This authorization remains effective as long as I am employed in the Georgia Merchant Acquirer Limited Purpose Bank
industry.
A copy of this authorization shall be accepted with the same force and validity as the original.
___________________________________
___________________________________________________
Type of Government ID Presented
Signature
___________________________________
Print Full Name
ID Number/Expiration
Print Alias
Street Address
City, State, Zip code
Social Security Number
Date of Birth
Sex
Race
(M or F)
B – Black
W – White
I – American Indian or
Alaskan Native
A – Asian or Pacific Islander
______________________________________________________
H - Hispanic
Date
___________________________________________
Witness
Rev March 2014
Complete Applicant Name (First, Middle, Last)
Name of Entity (Existing or Proposed)
BACKGROUND CHECK AUTHORIZATION FORM
TO WHOM IT MAY CONCERN:
I hereby authorize the Department of Banking and Finance (Department) to obtain criminal history data on the undersigned in his/her
capacity as a director, officer, principal, owner, policymaker, manager or employee of the above entity. I understand this will be a FBI
criminal background check. Also, pursuant to Section 7-9-7 of the Official Code of Georgia Annotated and the Rules of the Department
of Banking and Finance, the Department is authorized to obtain information regarding character, ethical reputation and financial
responsibility. Such information and any conviction data received by the Department shall be used by the Department for the exclusive
purpose of carrying out the responsibilities of this article, shall not be a public record, shall be privileged, and shall not be disclosed to
another person or agency except to any person or agency which otherwise has a legal right to inspect the file. In order to facilitate this
inquiry, I understand that I must provide the information below. The Department will notify me if further information is required. Should
the data show that a violation of the Georgia Merchant Acquirer Limited Purpose Bank Act and/or the Rules of the Department of
Banking and Finance exists, I understand that the Department may take the appropriate administrative action against me and/or the
affiliated entity. The procedures for changing, correcting, or updating a criminal history record is set forth in Title 28, Code of Federal
Regulations (CFR), Section 16.30 through 16.34.
This authorization remains effective as long as I am employed in the Georgia Merchant Acquirer Limited Purpose Bank
industry.
A copy of this authorization shall be accepted with the same force and validity as the original.
___________________________________
___________________________________________________
Type of Government ID Presented
Signature
___________________________________
Print Full Name
ID Number/Expiration
Print Alias
Street Address
City, State, Zip code
Social Security Number
Date of Birth
Sex
Race
(M or F)
B – Black
W – White
I – American Indian or
Alaskan Native
A – Asian or Pacific Islander
______________________________________________________
H - Hispanic
Date
___________________________________________
Witness
Rev March 2014