Bellingham Police Department

Internet Safety Class

Background Check Authorization

Last Name First Name Middle Name

Mailing Address City State Zip

Home Phone Number Date of Birth

( ) Month: Day: Year:

E-Mail Address

Occupation Drivers License/ID No:

By signing below, I hereby give the Bellingham Police Department permission to perform a background check (criminal history) on my name. I understand that the background check will be used in conjunction with the registration process for attendance in The Internet And Your Child – Internet Safety class being presented at the Bellingham Police Department.

Signature: _________________________ Date:_______________________

Failure to submit to this background check or a negative background history will void your registration.

PLEASE MAIL OR BRING THIS FORM TO:

Bellingham Police Department

Attention: Officer Tara Fleetwood

505 Grand Ave

Bellingham, WA 98225

(360) 676-6924

POL 412 10/03