S.T.Y.L.E. Mentor Information Release

Information Release

Question Title

* 1. I understand it will be necessary for S.T.Y.L.E. Mentoring Program to conduct a background check regarding my driving record, criminal history, personal references, and employment.

I authorize S.T.Y.L.E. Mentoring Program to obtain any needed information regarding my driving record, legal/criminal history, character references, and employment from any state or federal agency, my employer, and personal references for the purposes of participating in a mentoring program. Further, I provide permission for S.T.Y.L.E. Mentoring Program to conduct the same investigation of my background in previous states in which I have resided.

Once a mentor/mentee match is determined, my identity and any other information known about me may be shared with the mentee and parent/guardian to ensure and aid in facilitating a safe and successful match relationship.

Date

Date

Question Title

* 2. Please complete the follow items:

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Question Title

* 3. Date of Birth

Date

Date

Question Title

* 4. Current Driver's License Number & State

Driver's License Number

State

Question Title

* 5. Please list any other cities, states, and dates of residency during the past 10 years.

City, State From (m/year) To (m/year)

City, State From (m/year) To (m/year)

City, State From (m/year) To (m/year)

Question Title

* 6. Please type your name. This will represent your legal signature.