ACXIOM
Employment Screening Services Inc.
ATLANTIC AMATEUR HOCKEY ASSOCIATION
        BACKGROUND REQUEST FORM

NEW SCREENING FORM                                2009 - 2010
SECTION 1 SECTION 2 (Print or type information)    
Check State of Residence   Date:   _____/_____/_____
    Company Name:  AAHA/USA Hockey Account:  E8082315  
X Statewide Criminal Record Requestor Name:  AAHA  
  Check
  SECTION 3 (Print or type information)    
___ Delaware    
  Subject Name:  ___________________ ______ ____________________________
___ Pennsylvania   First M. Last  
     
___ New Jersey Address:  __________________________________________________________
     
___ New York City:   __________________________ State:  __________      Zip:  ____________
  Social Security Number Trace    
  All County Checks based on S.S.#:  __________ - ______ - ___________ D.O.B.:   _____/_____/_____
  Trace    
  Telephone:   ______________________________________________________
___ Maryland    
  Social Security Number Trace Club/Organization:  __________________________________________________
  All County Checks based on    
  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:   ____________________
                 
Need Additional Copies?  Please photocopy