SafeHaven Background Release & Confidentiality Form

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Groups you are affiliated with (if N/A, leave blank)

Name

First

Last

Address

Address Line 1

City

State

Zip Code

Phone

For identification purposes:

Date of Birth

Race

Gender

Former Names:

If none, leave it blank.

Counties Lived:

PLEASE LIST FORMER COUNTIES OTHER THAN THE TARRANT COUNTY IN WHICH YOU HAVE LIVED OR WORKED FOR THE PAST 5 YEARS. IF N/A, LEAVE IT BLANK.

you (if Email

Signature

Clear Signature

Type your Full Name. This constitutes your Electronic Signature.

Date