An LCMS Congregation
 
 
 

  Background Check Authorization Form


Please complete EVERY field. If information does not pertain to you, please answer with 'N/A'

I understand that this Background Authorization for volunteer positions is valid from:

   July 1, 2017 through June 30, 2018.


FOR EMPLOYMENT PURPOSES   

FOR VOLUNTEER PURPOSES (within the church)   
Please list the areas in which you wish to serve the church:

FOR VOLUNTEER PURPOSES (within the school)   
Please list the name of your student(s) currently enrolled in Concordia Lutheran School:
Please list the areas in which you wish to serve the school:

Please complete EVERY field. If information does not pertain to you, please answer with 'N/A'

* First Name:
* Middle Name:
* Last Name:
* Aliases:
* Maiden Name:

* Birth Date:

* Last 4 of SSN:
* Driver Lic State:
* Driver Lic Num:

Please complete EVERY field. If information does not pertain to you, please answer with 'N/A'

* Current Address:
* City:
* State: * Zip Code:

Check this box if you have resided at your current address five years or more.

Other addresses you resided at within the last five years:
(if not applicable, put 'N/A' in each Address, City, and do not select a State.)
Address City State

I hereby request and authorize the release of any information that pertains to any record of convictions contained in law enforcement files or in any criminal file maintained on me whether local, state, or national. I hereby release local, state, and national law enforcement agencies from any and all liability resulting from such disclosure. I further acknowledge that if a criminal background check is conducted, as may be required under the federal Child Abuse Prevention and Treatment Act, I may be denied access to children while the application is pending. I further understand that in accordance with this law, if I am denied a position because of a conviction that appears as a result of such search, I may challenge such information.

* Signed: Enter your name as your signature
* Date: Sep 23, 2017   This authorization form will expire on June 30, 2018


 


2017-09-23 16:45:38