Background Check Authorization printable pdf download

Background Check Authorization

Print Name: _____________________________________________________________

(First)

(Middle)

(Last)

Former Name(s) and Dates Used: ____________________________________________

(Maiden)

Year Married

_________________________________________________________

Current Address Since: ___________________________________________________

(Mo/Yr)

(Street)

(City)

(Zip/State)

Previous Address From: __________________________________________________

(Mo/Yr)

(Street)

(City)

(Zip/State)

Previous Address From: __________________________________________________

(Mo/Yr)

(Street)

(City)

(Zip/State)

Social Security Number: __________________ Date of Birth _____________________

Telephone Number:

___________________________________________________

Drivers License Number/State: ______________________________________________

The information contained in this application is correct to the best of my knowledge. I hereby authorize

Federal Way Foursquare Church, d.b.a. Northwest Church and its designated agents and represent-

atives to conduct comprehensive reviews of my background causing a consumer report and/or investi-

gative report to be periodically generated for the duration of my employment and/or volunteer status.

I understand that the scope of the consumer report/investigative consumer report may include, but is not

limited to the following areas: verification of social security number; current and previous residences;

employment history, education background, character references; drug testing, civil and criminal history

records from any criminal justice agency in any or all federal, state, county jurisdictions; driving records,

birth records, and any other public records.

I further authorize any individual, company, firm, corporation, or public agency (including the Social

Security Administration and law enforcement agencies) to divulge any and all information, verbal or

written, pertaining me, to Northwest Church or its agents. I further authorize the complete release of any

records or data pertaining to me which the individual, company, firm, corporation, or public agency may

have, to include information or data received from other sources.

I hereby release Northwest Church, the Social Security Administration, and its agents, officials,

representative, or assigned agencies, including officers, employees, or related personnel both individually

and collectively, from any and all liability for damages of whatever kind, which may, at any time result to

me, my heirs, family, or associates because of compliance with this authorization and request to release.

Signature: ________________________________________ Date: __________________

For Office Use Only: Ministry _________________________________

September 2008

Background Check Authorization

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