South Roxana, IL · Madison County
Background Check Authorization and Waiver Form
Permit applicants complete this form to authorize a background check and submit it with their permit application to the Village Clerk’s office.
What this form is
The form authorizes the Village of South Roxana to conduct a background check as part of considering a permit application. Applicants provide personal and permit information, authorize checks of criminal history and application details, and agree to the waiver. The instructions say to complete all applicant information, sign and date the form, and submit it with the permit application.
Who needs it
Anyone applying for a permit from the Village of South Roxana must complete this form and submit it with their permit application.
How to submit it
Complete and sign the form, then submit it with your permit application to the Village Clerk’s office.
About notarization
This form is signed and dated without a notary; the applicant just signs and dates it.
How to submit this form
- 1
Download the Form
Download the Background Check Authorization and Waiver Form.
- 2
Complete Applicant Information
Fill in the requested personal information and the permit type applied for.
- 3
Sign and Date
Read the authorization and waiver, then sign and date the form where indicated.
- 4
Submit With Permit Application
Submit the completed form with your permit application to the Village Clerk’s office.
Frequently asked questions
- Do I need a notary for the Background Check Authorization and Waiver Form?
- No. The applicant signs and dates this form; it does not call for a notary or mention a notarized or sworn attachment.
- Who completes this background check form?
- A person applying for a permit from the Village of South Roxana completes the applicant information and authorizes the background check.
- How do I submit the form?
- Complete all fields, sign and date the form, and submit it with your permit application to the Village Clerk’s office.