Extended Background Check (EBC) Authorization Form CONSENT TO PERFORM CRIMINAL HISTORY BACKGROUND CHECK IN COMPLIANCE WITH THE FCRA (FAIR CREDIT REPORTING ACT) Date: Last Name Middle Name First Name Maiden and/or Other Last Names Used Address Phone Number City (1) (2) State Zip Code List last two Counties that you lived in Date of Birth Social Security Number Circle One: Male Female This authorization and consent for release of personal information acknowledges that Oklahoma Board of Social Work Licensure (Hereafter referred to as "Company") and/or its agent, Trak-1 Technology, may now conduct investigations whether the records are of a public, private or confidential nature..
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