Student Pre-Enrollment Background Inquiry Release

In connection with my Admissions Application with United Tribes Technical College, I understand that: 

• investigative background inquiries are to be made on myself. These reports will include information from various federal, state and other agencies which maintain records concerning my past activities relating to my driving, criminal, civil and other experiences.
• Additionally, I authorize you to contact probation officers of any
  agency overseeing my release.

I authorize, without reservation, any party or agency contacted by this employer or this employer’s representative to furnish the aforementioned information. 

Candidate ID

First Name

Middle

Last Name

Email

Phone Number

Date of Birth

Social Security Number

Planned Enrollment Start Date

Program of interest

Prospective College: United Tribes Technical College

Present Address

Address Line 1

Address Line 2

City

State

Zip

Physical addresses for the past five years are required. Incomplete forms cannot be processed. 

Previous Address 1

Address Line 1

Address Line 2

City

State

Zip

Previous Address 2

Address Line 1

Address Line 2

City

State

Zip

Previous Address 3

Address Line 1

Address Line 2

City

State

Zip

Previous Address 4

Address Line 1

Address Line 2

City

State

Zip

Other Important Information

List additional places of residency including Reservation(s), any convictions, i.e., State and/or Tribal, etc.

Tribal Affiliation(s)

Include agency and enrollment number, if available.

Electronic Signature

By typing your full legal name below, you certify that the information provided is true and complete and that this electronic signature has the same legal effect as a handwritten signature.