Choices in Living Counseling Centers, Inc.


REQUEST FOR CBI REPORT 








        Dear Choices in Living Counseling Centers, Inc.,

        Please consider this my written request for Choices in Living Counseling Centers, Inc. to obtain and send me my 
        current CBI Report. My email address where the Report should be sent is:                                                                           (required)

        MY FULL NAME: 

              First Name:                                                                                      (required)

              Middle Name:                                        

              Last Name                                                                                        (required)

              Date of Birth:                                                                                   (required)

              Social Security No.:                                                                      (required)

             I attest that to the best of my knowledge the information that I have provided contained within is true and correct.
             I understand that Choices’ charges $15.00 for each CBI Report that I request and that I am liable for such costs. 
             By completing this form and by placing a "CHECKMARK"  in the box below, I affirm my request and  I agree to
             hold harmless Choices in Living Counseling Centers, Inc.,HSC LLC dba Choices Counseling Centers, all Choices 
             Staff, Independent Contractors, and Administrative Personnel, and the Colorado Bureau of Investigation about the 
             information I have submitted and the results obtained from my information.



             By clicking the submit button, you are emailing this request to:   Choices in Living Counseling Centers, Inc.




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