MWR
GUEST
PASS
Authorization
to
Conduct
Background
Investigations
I
hereby
authorize
and
consent
to
the
release
of
information
and
records
bearing
on
my
personal
history,
arrests
and
convictions,
if
any,
to:
LexisNexis
Screening
Solutions,
Inc.,
and
its
subsidiaries,
affiliates,
officers,
agents,
and
employees,
the
Morale,
Welfare
and
Recreation
Department
and
Naval
Station
Mayport.
The
information
will
be
used
for
the
sole
purpose
of
determining
my
access
to
Naval
Station
Mayport
and
the
Morale,
Welfare
and
Recreation
Department’s
facilities
and
that
the
execution
of
this
form
is
voluntary.
This
authorization
is
valid
for
one
year
after
my
signing.
Upon
request,
a
copy
of
this
signed
statement
may
be
furnished
to
the
criminal
justice
agency
or
other
person
furnishing
such
information
or
record.
I
release
LexisNexis
Screening
Solutions,
Inc.,
and/or
its
agents
and
any
person
or
entity,
which
provides
information
pursuant
to
this
authorization,
from
any
and
all
liabilities,
claims
or
law
suits
in
regards
to
the
information
obtained
from
any
and
all
sources
used.
The
following
is
my
true
and
complete
legal
name
and
all
information
contained
herein
is
true
and
correct
to
the
best
of
my
knowledge.
PLEASE
PRINT
CLEARLY---PLEASE
PRINT
CLEARLY----PLEASE
PRINT
CLEARLY
Print
Name:
______________________________________________________________________
First
Name
Middle
Name
Last
Name
Phone
Numbers:
____________________________
(hm)
______________________________
(wk)
Signature:
___________________________________
Date:
____________________________
Date
of
Birth
(for
identification
purposes
only)
___________________________________________
Social
Security
Number
(for
identification
purposes
only)
__________________________________
Print
former
name
if
name
changed
(going
back
7
years
only):
_____________________________
(through
marriage
(maiden)
or
otherwise)
THERE
IS
A
$15.00
CHARGE
FOR
EACH
COUNTY
SEARCHED.
(NONREFUNDABLE)
PLEASE
SUBMIT
CASH,
CREDIT
CARD
OR
CHECK
PAYABLE
TO
MWR
FUND
FOR
THE
TOTAL
COST.
Current
Street
Address:____________________________________________________________
City:
___________________________
State:
________
Zip
Code:
____________________
List
previous
residences
(going
back
2
years
only),
each
additional
county
cost
$15.00.
City:
___________________________
State:
__________
County:
___________________
City:
___________________________
State:
__________
County:
___________________
-------------------------------------------------------------------------------------------------------------------------------
ITT
