Volunteer Authorization and Consent Form

AUTHORIZATION AND CONSENT FOR RELEASE OF INFORMATION

(APPLICANTS 18 YRS AND OLDER PLEASE COMPLETE ALL INFORMATION)
Full Name *

Prefix First Name Middle Name Last Name
Birth Date *

Month Day Year
Driver's License Number: *
State Issued *
Current Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Years at Address: *
Phone Number *

Area Code Phone Number
Email *
example@example.com
Social Media
Previous Addresses in Last Seven (7) Years
Previous Address 1

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Number of Years at Address 1:
Previous Address 2

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Number of Years at Address 2:
Previous Address 3

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Number of Years at Address 3:
Consent for Release of Information
Applicant's Signature *

Clear
Name *

First Name Last Name
Date of Submission

Month Day Year Hour Minutes AM/PM Option
Enter the message as it's shown *
Should be Empty:

AUTHORIZATION AND CONSENT FOR RELEASE OF INFORMATION