ACXIOM
Employment Screening Services Inc.
		ATLANTIC AMATEUR HOCKEY ASSOCIATION
BACKGROUND REQUEST FORM
NEW SCREENING FORM                                2007 - 2008
25% CHECK
SECTION 1		SECTION 2 (Print or type information)
Check State of Residence
						Date:	_____/_____/_____
X	Statewide Criminal Record	Company Name:  AAHA/USA Hockey				Account:  E8082315
	Check	Requestor Name:  AAHA
___	Delaware	SECTION 3 (Print or type information)
___	Pennsylvania	Subject Name:	___________________ ______ ____________________________
			First		M.	Last
___	New Jersey
		Address:  __________________________________________________________
___	New York
	Social Security Number Trace	City:   __________________________			State:  __________      Zip:  ____________
	All County Checks based on
	Trace	S.S.#:  __________ - ______ - ___________				D.O.B.:	_____/_____/_____
___	Maryland	Telephone:	______________________________________________________
	Social Security Number Trace
	All County Checks based on	Club/Organization:  __________________________________________________
	Trace
		Coach:  ____________________________   Volunteer:  ____________________
Instructions for Screening:
	1.  All new coaches and volunteers to your organization must complete this form.
	2.  Please instruct participant to complete Section's 1, 2 and 3 and sign below.  All information must be
	filled in or this application will be rejected.
	3.  Please make your check for $35.00 payable to AAHA.
	4.  Return this completed form and payment to:
			Atlantic District Executive Office
			c/o Flyers Skate Zone
			601 Laurel Oak Road
			Voorhees, NJ   08043
I certify that all information given by me in this application is true and correct to the best of my knowledge.  I understand
that false or misleading statements made by me or consequential omissions of any kind in the application process are
significant cause for my not being accepted as a volunteer/employee or for my dismissal no matter when discovered.  I
authorize Atlantic Amateur Hockey Association to investigate all information contained in this application.
Signature:  _________________________________________________________						Date:   ____________________
AFS-01-01
Need Additional Copies?  Please photocopy