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Sample Church Background Check Template

A template to use when conducting a background check for future potential church employees or volunteers.







Church Background Check Template



Church Background Check


Name: __________________________

Maiden or other name(s) in any and all other records of birth or records of residence:

________________________________

Address: _________________________

City: __________ State: ___ Zip: ____ Date of Birth: ____/____/______

Place of Birth: _______________

Social Security Number:

________________________________

Gender: [__] Male [__] Female

Race: ____________________

Drivers License Number:

_______________________ State ____

Do you have a Photo ID?

[__] Yes [__] No

Home Phone: _____________________

Cell Phone: _____________________

Email: _________________________

Emergency Contact:

________________________________

Emergency Contact Phone Number:

________________________________

NOTE: THE FOLLOWING IS TO BE USED FOR CRIMINAL HISTORY CHECKS ONLY AND NOT TO BE APART OF THE PERSONNEL FILE

References - Name / Phone Number

1. ____________________________

2. ____________________________

3. ____________________________


I, ___________________, am an applicant for employment / volunteer work with _________________ church / division and have been advised that as a part of the application process, the church / division conducts a criminal history background check. I do hereby consent to the church / division to use any information that is provided in this application to perform a criminal history check. The church / division has informed me that I have the right to review and challenge any negative information that would adversely impact a decision to offer volunteer / employment work. In addition, I have been informed that I will have a reasonable opportunity to clear up any mistaken information reported within a reasonable time frame established within the sole discretion of the church / division. Under the Fair Credit Reporting Act, I have been advised that upon request I will be provided the name, address and telephone number of the reporting agency as well as the nature, substance and source of all information.

The following are my responses to questions about my criminal history (if any):

1. Have you ever been convicted or plead guilty before a court for any federal, state or municipal criminal offense? (Excluding minor traffic misdemeanors). [__] Yes [__] No

If yes, please provide the details below:

State: _________ County: __________________ Date of Offense: ____/____/______

Details of Conviction: ____________________________

2. Have you ever received deferred adjudication or similar disposition for any federal, state or municipal offense?

[__] Yes [__] No

If yes, please provide the details below:

State: _________ County: __________________ Date of Offense: ____/____/______

Details of Conviction: ____________________________

3. Have you ever received probation or community supervision for any federal, state or municipal offense?

If yes, please provide the details below:

State: _________ County: __________________ Date of Offense: ____/____/______

Details of Conviction: ____________________________

4. Have you ever been convicted of any criminal offense in a country outside of the jurisdiction of the United States?

If yes, please provide the details below:

State: _________ County: __________________ Date of Offense: ____/____/______

Details of Conviction: ____________________________

5. As of the date of this consent form, do you have any pending charges against you?

If yes, please provide the details below:

State: _________ County: __________________ Date of Offense: ____/____/______

Details of Conviction: ____________________________

Please list all counties and states of residence since the age of eighteen:

City / Town County State Country

____________________________

____________________________

____________________________

____________________________

____________________________

I hereby certify that all the information that is provided in this consent form is true, correct and complete. All Offers of Employment / Volunteer are contingent upon the applicant's successful completion, as determined by the employer's sole discretion, of this criminal history / background check.


____________________________
Signature of the Applicant


Authorized Person Requesting a Background Check:


Print Name:

____________________________


Signature:

_______________________ Date_____





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