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North Georgia College State University Public Safety Consent Form I hereby authorize Lori Brooksher with North Georgia College State University s School of Education to receive any Georgia criminal history record information pertaining to me which may be in the files of any state or local criminal agency in Georgia. Full Name print Address print Sex Race Height Eyes Date of Birth Signature Social Security Number Date Special employment provisions check if applicable Employment with mentally disabled Purpose code M Other EmploymentReal Est. Lic.Housing Purpose code E One of the following must be checked This authorization is valid for 90 or 180 check one days from the date of signature. history background checks for the duration of my employment with this company. Requested B y Public Safety Office USE ONLY Operator Purpose C Date. North Georgia College State University Public Safety Consent Form I hereby authorize Lori Brooksher with North Georgia College State University s School of Education to receive any Georgia criminal history record information pertaining to me which may be in the files of any state or local criminal agency in Georgia* Full Name print Address print Sex Race Height Eyes Date of Birth Signature Social Security Number Date Special employment provisions check if applicable Employment with mentally disabled Purpose code M Other EmploymentReal Est. Lic*Housing Purpose code E One of the following must be checked This authorization is valid for 90 or 180 check one days from the date of signature. history background checks for the duration of my employment with this company. Requested B y Public Safety Office USE ONLY Operator Purpose C Date. North Georgia College State University Public Safety Consent Form I hereby authorize Lori Brooksher with North Georgia College State University s School of Education to receive any Georgia criminal history record information pertaining to me which may be in the files of any state or local criminal agency in Georgia* Full Name print Address print Sex Race Height Eyes Date of Birth Signature Social Security Number Date Special employment provisions check if applicable Employment with mentally disabled Purpose code M Other EmploymentReal Est. Lic*Housing Purpose code E One of the following must be checked This authorization is valid for 90 or 180 check one days from the date of signature. Lic*Housing Purpose code E One of the following must be checked This authorization is valid for 90 or 180 check one days from the date of signature. history background checks for the duration of my employment with this company. Requested B y Public Safety Office USE ONLY Operator Purpose C Date. .