Background Check Authorization

Authorization to Obtain Criminal History

We are required to verify the criminal history of all household members 18 years and older who are applying to live in properties. The property you are living in or applying to live in falls under this regulation.

Name (Last, First, Middle)

Social Security Number

Date of Birth

Other Names Used (Last, First, Middle)

List all cities and counties in Virginia in which you have resided

List all areas other than Virginia in which you have resided (please specify city/state)

I consent to allow Community Services Housing, Inc. to obtain information regarding my criminal background from any source deemed appropriate including but not limited to law enforcement agencies, judicial entities or private screening companies. I understand that this information will only be used to determine eligibility for PRAC 811 housing through Community Services Housing, Inc., and that a criminal history does not automatically determine me to be ineligible for housing in this program.

Select a date

Your Signature

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!