Background Check Consent
I,
Your Full Name
authorize Pediatric Advanced Therapy to conduct a background/sex offender check.
I have lived in the following states:
My maiden name is:
Date of Birth
-
Month
-
Day
Year
Date
Social Security Number
Gender
Male
Female
Current Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Signature
Clear
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: