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<br /> ORANGE COUNTY SPORTSPLEX <br /> Background Check Form <br /> <br />The Orange County Sportsplex conducts criminal and traffic record searches on applicants or employees, in <br />accordance with our hiring policies. Your signature on this form (below) will give us permission to conduct a <br />search of all criminal and traffic records listed with your name, date of birth, and social security number. Should <br />you have any questions regarding this background check, please talk with the Director who is hiring for the <br />position you seek or talk with the Sportsplex Assistant General Manager. We appreciate your cooperation. <br /> <br />Please P – R – I – N - T <br /> <br />LAST <br />NAME <br /> <br />MIDDLE FIRST <br />INITIAL NAME <br /> <br />If you name has changed within the past 10 years, please print your previous name(s) below: <br /> <br />______________________________________________________________ Date changed: ________________ <br /> <br />Telephone/Cell number: _____________________________________________________________________ <br /> <br /> <br />Date of Birth: Month .Day vvvvvYear <br /> <br /> <br />Social Security Number: <br /> <br /> <br />Driver’s License Number: <br /> <br />(Beginning with the first box, list the numbers of your license. Disregard any leftover boxes.) <br /> <br />List the County and State that issued your Driver’s License: <br /> <br />County: ____________________________________________ State: ____________________ <br /> <br />Please list the names of all the places where you lived during the past 5 years: <br /> <br />City: __________________________ State: _______ County: __________________ Dates: _______ to _______ <br /> <br />City: __________________________ State: _______ County: __________________ Dates: _______ to _______ <br /> <br />City: __________________________ State: _______ County: __________________ Dates: _______ to _______ <br /> <br />Applicant Signature: _______________________________________________ Date: _____________________ <br /> <br />Applicants should not write below this point <br />An Orange County Sportsplex Staff person must sign this form in order to generate the background search: <br /> <br />PRINT Name: _____________________________________________________________________________ <br /> <br />Signature: ____________________________________________________ Date: ______________________ <br /> <br /> <br /> <br /> <br /> <br />Docusign Envelope ID: 177AA06A-30B4-42FF-A85A-78B5A7C51DBE