LEASE ADDENDUM FOR CRIME-FREE/DRUG FREE HOUSING
Criminal Background Check Consent Form
Applicant: ________________________________________
A Local Records Check of the St. Cloud Police Department/Stearns County Sheriffs Department and a Search of the Minnesota State Criminal Records and/or the Federal Bureau of Investigations Criminal Justice Information files will be performed on you pursuant with your lease agreement with KENT HOUSING. By signing this form you are allowing the St. Cloud Police Department to release the criminal data maintained in those files which applies under Statutes and Ordinances.
1. You have the right to be informed that Kent Housing is requesting a Criminal Background Check to determine if you have been convicted of a Crime Specified in Section 299.67, sub. 2
1. You have the right to be informed by Kent Housing of the results of a Criminal Background check and to obtain a copy of the results.
1. You have the right to obtain from St. Cloud Police Department/Stearns County Sheriff’s Department and/or The Bureau of Criminal Apprehension, any records that form the basis for the report obtained.
1. You have the right to challenge the accuracy and completeness of information contained in the report or record under section 13.04, sub. 4.
1. You have the right to be informed by Kent Housing if your application for acceptance has been denied because of the results of this Background Check.
Applicant Information - PLEASE PRINT CLEARLY
_________________________________________________________________________________
Last Name First Name Middle Name
Have you been known by another name? Maiden, Aliases __________________________________
Date of Birth ___________________ Gender: Male ____ Female ____ Race: _____________
Driver Lic. # ____________________ State: _______ Social Security # ______________________
__________________________________________________________________________________
Current Address Apt # City State/Zip County
Have you lived in Minnesota for at least the past 5 years? Yes_____ No_____
__________________________________________________________________________________
Prior Address Apt # City State/Zip County
This release shall be effective for ONE (1) year from the date signed.
_______________________________________ ______________________________
Applicant Signature Date
Subscribed and sworn before me on this
_____ day of ___________ , 20 _____
______________________________
Notary Public
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