CRIMINAL RECORD CHECK

ROSE CAPITAL WEST LITTLE LEAGUE   

P. O. BOX 7241 TYLER TX 75711

NAME____________________________________________________________

ADDRESS __ ______________________________________________________

                    Street Address

 __________________________________________________________________

  City                          County                          State                     Zip Code

PHONE (__________)_______________________  

Other names by which you may have been known, if any.

 __________________________________________________________________

(Note: May include maiden name or names that were changed for other reasons.)

I hereby authorize the local Police Department and other local, state or federal agencies to release any record that may be on file in my name(s) in the records of said agencies.  Any such information will become part of my application for a manager or coach position with the Rose Capital West Little League in Tyler, Texas.

Legal Signature ______________________________________ 

Date of Birth _______________

Social Security Number __________-_________-__________

Driver’s License No. ___________________________ 

State ___________________________