Informed Consent Form - Minnesota
Sample Informed Consent
Company Name
Street Address
City, State and Zip
Phone
Date: ___________________________
The following named individual has made application with this agency for (employment, volunteering, adoption, etc.) .
Last Name of Applicant (please print): _____________________________________
First Name (please print): _______________________________________________
Middle (full)(please print): _________________________________________________
Maiden, Alias or Former(please print): _____________________________________
Date of Birth: ____________________ Sex (M or F): ______________
Month/Day/Year
Social Security Number (optional): ________________________________________
I authorize the Minnesota Bureau of Criminal Apprehension to disclose all criminal history record information to (Company Name or Specific Individual) for the purpose of (employment, volunteering, adoption, etc.) with this agency.
The expiration of this authorization shall be one year from the date of my signature.
Signature of Applicant _________________________ Date _____________
Notary:
Note: This form is meant as an example of the type of informed consent that is acceptable. Your agency is responsible for designing the form to reflect the specific legislation or rules under which your request is being initiated. Please refer to the rules and regulations that requested your compliance to assure that your particular form will meet those requirements.
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