Good Samaritan House Background Check Release Form Name * First Name Last Name Date of Birth * MM DD YYYY SSN * Now comes the undersigned, being an applicant for services provided by Good Samaritan House and hereby authorizes Good Samaritan House, individually and operating as Good Samaritan House, (collectively “the shelter”), to obtain the performance of a criminal background check on the undersigned as part of the Shelter’s procedure to determine whether or not the undersigned qualifies for services provided by the Shelter. The undersigned further releases and holds harmless Good Samaritan House and the agents, employees, directors, officers, executive director and members thereof from any and all liability of any type arising out of or for which the competent producing cause is the criminal background check or any information or damages arising therefrom. The undersigned further acknowledges that the background check may be performed by any law enforcement agency of the Shelter’s choosing. To submit your application, you must affirm that all information you completed above is correct. By entering your digital signature below, you are affirming UNDER PENALTY OF PERJURY that all the information is correct. Typing your name in the box below will constitute your electronic signature: * Today's Date * MM DD YYYY By clicking on the "Confirm" button below, I am affixing my electronic signature, which is legally equivalent to my handwritten signature. Thank you!