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Consent Form
for
Criminal Back Ground information Check
My signature below authorizes, Inc. ALLIED MEDICAL STAFFING. to obtain any criminal history record information pertaining to me which may be in the files of any state or local criminal justice agency in the United States of America. I understand that this information will be used to evaluate my qualification for referral to specific assignments through
ALLIED MEDICAL STAFFING.
FULL NAME
ADDRESS
SIGNATURE
DATE
WITNESS
DATE