Criminal Check Release Crawford County Commission on Aging Criminal History Information Questionnaire I authorize Crawford County Commission on Aging (COA), 308 Lawndale St., Grayling, MI 49738, to obtain a criminal history report(s) during the employment/volunteer application process. I understand that such reports may also be obtained annually during my employment or volunteer service with COA, if required by a program, contract or a need is identified. In order to obtain this report, the following information is required and will be kept confidential. It will be maintained in a separate file from my application. The information provided below will only be used to identify my criminal history, if any. I have read this form and I am providing this information on a voluntary basis. I acknowledge that I am signing this form as a normal part of the COA employment/volunteer process. Which one applies to the reason you are filling out this form?* Employee Employee Applicant Volunteer Gender*FemaleMaleDate of Birth* MM slash DD slash YYYY Name* First Middle Last If you do not have a middle name, type in N/A in the middle name field.Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Race* White Black Hispanic Asian/Pacific Islander American Indian Email Provide any other name(s) previously used (include aliases, maiden, married or N/A):* Today's Date* MM slash DD slash YYYY Authorization* By checking this box, I hereby authorize Crawford County Commission on Aging to conduct criminal history check(s).