HomeMy WebLinkAboutCriminal History FormLansing City Clerk’s Office
Ninth Floor, City Hall, 124 W. Michigan Ave., Lansing, MI 48933-1695
517-483-4131 • TDD 517-483-4479• 517-377-0068 FAX
www.lansingmi.gov/clerk • clerk@lansingmi.gov
Criminal History Record Check Authorization
As part of the Licensing process, we need you to complete the background and criminal
history record check authorization below. This information must be returned with your
application to the Lansing City Clerk's Office, 9th Floor City Hall, 124 W Michigan Ave,
Lansing, MI 48933. Please call (517) 483-4133 if you have any questions.
Complete a separate form for each individual subject to background check.
Applicant, stakeholder(s), and all employees must fill out this form.
Date: ______________
I ____________________________ authorize the release of any and all information from
any appropriate agency regarding my criminal conviction history to the Lansing City Clerk's
Office. I understand that my ethnicity, date of birth, sex and my age will not be made a part
of my Application and that none of these four (4) items will be considered in the review of
my License.
I acknowledge that a complete full background investigation, including, but not, limited to a
State Police Criminal Conviction Record Check will be done.
I further understand that the Lansing City Clerk's Office has the right to deny my License
based upon the results of this investigation.
(Please Print Clearly)
Full Name: _______________________________________________________________
First Middle Last Maiden/Other
Date of Birth: _______________ Sex:_____________ Race: __________________
Social Security No: ____________________ Driver's License # ____________________
List all names ever used: ____________________________________________________
_______________________________
Signature
Chris Swope
Lansing City Clerk