DO NOT EMAIL THIS FORM.

AN ORIGINAL SIGNATURE IS REQUIRED BY THE SHERIFF'S OFFICE.

Jefferson Parish Sheriff’s Office

1233 Westbank Expressway

Harvey, LA 70058

Please conduct a criminal background check on the below listed subject:

Company/Agency Name: Jefferson Community School___________________

Mailing Address: 3528 Montford St.___________________________________

City  State  Zip Code: Jefferson, LA 70121______________________________

                                                                 ________________________________

                                                                 Signature of Company/Agency Official

ALL INFORMATION ON SUBJECT MUST BE TYPED EXCEPT FOR THE SIGNATURE.

Name:________________________________________________________________________

                 Last                                                        First                                Middle/Maiden

Sex:____Date of Birth:_______________Social Security No.:__________________________

Address:______________________________________________________________________

                  Numerical                                     City                            State                        Zip

_______________________________________     By this signature I authorize the Jefferson

SIGNATURE OF ABOVE LISTED SUBJECT       Parish Sheriff’s Office to conduct a

                                                                                   criminal history background check on

                                                                                   myself, and waive such legal fights that

                                                                                   exsist and do release any and all persons

                                                                                   from liability in connection with the

                                                                                   processing of this criminal history

                                                                                   background check.

Important:  This criminal history background check is only processed through the files of the Jefferson Parish Sheriff’s Office.  Our office is unable to conduct a criminal history background check through the files of other agencies.  The results of this criminal history background check does not preclude the possibility of an existing criminal history on this subject with another law enforcement agency.

The Jefferson Parish Sheriff’s Office cannot make an accurate identification based on name, sex and date of birth only.

_____________________________________________________DATE___________________

Deputy Sheriff Technical Services Bureau                             

[   ] NO CRIMINAL HISTORY FOUND