This report is for:    ____DMV check only   ____Criminal Background only   ____Both

Driver’s License:  ___Virginia ___Other state             Applying: ___ Fire___ Rescue___ Both

Please print the following information in VERY legible handwriting:

________________________       __________________    ___________________      ______
         (Last Name)                                   First Name)                   (Full Middle)             (Suffix)

If you have been married, please give maiden name:  ____________________________

Sex:  ____Male    ____Female           Race:  ___White ___African American ____Other:

Date of Birth:   ________________________ (mm/dd/yyyy)

Social Security Number:  ___________ - ______ - ___________


I hereby certify that all information on this form to be used for a Criminal Background check and DMV check on myself are true and complete.  Results of this check may be disseminated for the purpose of determining membership eligibility in any Botetourt County Emergency Service agency.  I will not hold Botetourt County or the agency which I have applied with, responsible for any negative results that may, in the course of running my criminal history, be discovered.

Signature of applicant:_____________________________________   

Date:________________________




NOTE TO CAPTAIN/CHIEF/OTHER:
- Allow up to 3 days to receive report information
- Please provide the following information:

Your name:____________________________   Squad or department:___________________
I would like to be notified by _______email, or by _______phone the background results.

Email:______________________________  Telephone:______________________________