Privacy Act Statement

Instructions: Please complete all items and completely. The information you provide will remain confidential and will be used for the purpose of assisting you with your situation. Please let us know if you require assistance or have any questions

Principal Purpose: The information you provide will help SEVEN STARTS professional staff to assist you. In addition your information may be disclosed in certain other specific circumstances, as permitted by exceptions to the Privacy Privacy could include clearance, personnel reliability programs, and referrals.

Signature Indicates that you:

Have read and understand the Privacy Act Statement
Have read and received a copy of the client's bill of right and responsabilities

AGREEMENT: By signing this Electronic Signature Acknowledgment Form, I agree that my electronic signature is the legally binding equivalent to my handwritten signature. Whenever I execute an electronic signature, it has the same validity and meaning as my handwritten signature. I will not, at any time in the future, repudiate the meaning of my electronic signature or claim that my electronic signature is not legally binding.

I understand that checking this box constitutes a legal signature confirming that I acknowledge and warrant the truthfulness of the information provided in this document

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