Church Background Check
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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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