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PLEASE PRINT
Your Name _______________________________________________________
First Middle
Initial Last
Any other name you have used
Additional Name _______________________________________________________
First Middle
Initial Last
Home Address _______________________________________________________
City State Zip
Date of birth _____/_____/_____
Social Security Number __________________
Gender ________________
Driver's License Number _______________________ State
__________________
I hereby give consent for an investigative consumer report to
be prepared to determine my eligibility for membership. I understand
that this report may include information about me obtained from
Law Enforcement Agencies, State Agencies, Consumer Credit Reports,
and Social Security information, as well as Public Records information
such as Criminal History information and Civil Records such as
are allowed by law. I also attest that the above supplied information
was given voluntarily and I understand that it is to be used for
the purposes of verifying my identity in acquiring public information
and for no other purposes.
Signature ___________________________________ Date
__________________
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