Background Check Information

All students must fill out this form. Please fill out all information accurately.

Student's Legal First Name*
Student's Legal Middle Name*
(If none, put N/A)
Student's Legal Last Name*
Date of Birth*

(mm/dd/yyyy. Example: March 12, 1996 = 03/12/1996)
Social Security Number*
International YAs, just enter 000-00-0000
License/Passport Number*
License State OR Passport Country
State / Province / Region Country
Mobile Phone*
Student Email*
Enter Email Confirm Email
Current Street Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Start Date of Residency*
This is when you began living at this address.
Ending Date of Residency*
This is when you stopped living at this address. If you still live here, enter your move-in date.
Previous Street Address (if any, for previous 7 years)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Start Date of Residency
This is when you started living at this above.
Ending Date of Residency
This is when you stopped living at this address. It should be the same day as when you moved to the first address entered.
Have you ever been evicted?*
- Yes
- No
Have you ever been convicted of a felony?*
- Yes
- No
Do you have any criminal charges pending, awaiting disposition or looming in any way?*
- Yes
- No
Acknowledgment.I have carefully read and understand this notice and authorization form and by my signature below, consent to the release of consumer or investigative consumer reports, as defined above in conjunction with my application, during the entire course of my membership, if any, and after any such membership ends. I further understand that any and all information contained in my application or otherwise disclosed to The Young Americans, by me before, during or after my membership, if any, may be utilized for the purpose of obtaining the consumer reports or investigative consumer reports requested by The Young Americans and confirm that all such information provided in connection with my application is true and correct. I understand and acknowledge that nothing in this notice and authorization is intended to be, or is, an offer of membership or a promise of continued membership. If accepted, my membership will not be for a specified period of time and can be terminated at any time for any reason, with or without cause or notice, by me or by The Young Americans. I understand that the release of consumer reports to which I am consenting will be considered for membership purposes.
Picture of Signature*
Accepted file types: jpg, jpeg, gif, png, pdf.
Please upload a picture of your signature
Email
This field is for validation purposes and should be left unchanged.

If the name on the card being used for payment is different than your name, please enter your name in the Special Instructions box during checkout.