Signature: ______________________________ Date Signed: _________________

For Internal Use Only: No Criminal Record Found Criminal Record Found Please See Attached

Background Check Authorization

Print Legal Name: ____________________________________________________ First Middle Last

Date of Birth: _______/_______/________ Social Security No.: _____________________

Driver’s License Number: ________________________ State Issued: ________________

Gender: Male Female Place of Birth: ________________________________________

Ethnicity: ____________________________ Alias: ______________________________

Height: __________ Weight: __________ Hair Color: __________ Eye Color: __________

Home No.: (_______)____________________ Cell No.: (_______)____________________

Please List Last Five Years Residential Addresses Starting With Most Recent:

House No. Street Name City State Zip Code

House No. Street Name City State Zip Code

House No. Street Name City State Zip Code

House No. Street Name City State Zip Code

Check One: Umpire / League Official Team Manager / Assistant Coach / Dug-out Parent

Team Name: ______________________________________________________________

Team Age: T-Ball (6U) Coach Pitch (8U) Kid Pitch (10U) Bronco (12U) Pure Pony (13/14U)

I hereby authorize Kaufman Lions Club Baseball / Softball League and its designated agents and representatives to conduct a

comprehensive review of my background for volunteer and/or informational purposes only. I understand that the scope of the

background report may include, but is not limited to, the following areas: verification of current and previous residences, criminal

history records from any criminal justice agency in any or all federal, state, county jurisdictions, and any other public records.

Kaufman Lions Club Baseball / Softball League and its designated agents and representatives shall maintain all information

received from this authorization in a confidential manner in order to protect personal information, including, but not limited to,

addresses, social security number, and date of birth. Kaufman Lions Club Baseball / Softball League is not responsible for any

incorrect or unknown information discovered during the course of this background investigation.