Ccsw Personal Disclosure Form Page 2

ADVERTISEMENT

Background Verification Release Form
AGENCY INFORMATION
Date
Agency Name
Trinity-Brazos Area of the Christian Church (Disciples of Christ) in the Southwest
Contact Name
Office Manager
Agency’s Main Phone Number
Agency’s Fax Number
817-831-4442
817-831-4446
APPLICANT INFORMATION:
Applicant Full Name (Last, First, MI)
Maiden or Other Name(s) Used
Current Address
City
State
Zip Code
County
Driver’s License Number
Social Security Number
Date of Birth
State Issued
Position Applied For
 African American  American Indian  Anglo  Asian  Hispanic  Other
 Male  Female
Gender
Race
I hereby authorize
FYI and or its Service Provider to request and receive any and all background information
VERI
about or concerning me, including but not limited to my Criminal History, Social Security Number Trace including a
consumer report under the Fair Credit Reporting Act, 15 U.S.C 1681, Driving Record, Employment History, Military
Background, Civil Listings, Educational Background, Professional License from any Individual, Corporation,
Partnership, Law Enforcement Agency, and other entities including my Present and Past Employers.
The criminal history, as received from the reporting agencies, may include arrest and conviction data as well as plea
bargains and deferred adjudications and delinquent conduct as committed as a juvenile. I understand that this
information will be used, in part, to determine my eligibility for an employment/volunteer position with this
organization. I also understand that as long as I remain an employee or volunteer here, the criminal history check
may be repeated at any time. I understand that I will have an opportunity to review the criminal history as received by
client/agency and a procedure is available for clarification, if I dispute the record as received. I also understand that
the criminal history could contain information presumed to be expunged.
I further release and discharge
FYI and their Service Provider and all of their Subsidiaries, Affiliates, Officers,
VERI
Employees, Contract Personnel, or Associates, from any and all claims and liability arising out of any request for
information or records pursuant to this authorization, procurement of an investigative consumer report and
understand that it may contain information about my character, general reputation, personal characteristics, and
mode of living, whichever are applicable.
I understand that I have the right to make written request within a reasonable period of time to
FYI for additional
VERI
information concerning the nature and scope of the investigation. I acknowledge that I have voluntarily provided the
above information for employment/volunteer purposes, and I have carefully read and understand this authorization
.
Applicant’s Signature
Date
Applicant’s Printed Name
Parent/Guardian’s Signature
(if under 18 years of age)
FORM D
Page 2
– Apr 2015

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

State Form 46781 - Personal Disclosure Form 2 State Form 46781 - Personal Disclosure Form 2 Legal
Personal History Disclosure Form Personal History Disclosure Form Legal
Personal Information Form And Authorization Of Indirect Collection, Use And Disclosure Of Personal Information Personal Information Form And Authorization Of Indirect Collection, Use And Disclosure Of Personal Information Business
Form B: Medical Disclosure Form (child) - Parks, Recreation And Culture Department Form B: Medical Disclosure Form (child) - Parks, Recreation And Culture Department Legal
Disclosure Form For Military Sales Disclosure Form For Military Sales Legal
Form Dlc4031 Ohio Department Of Commerce Division Of Liquor Control - Partnership Disclosure Form Form Dlc4031 Ohio Department Of Commerce Division Of Liquor Control - Partnership Disclosure Form Business
Form Rv-f1404701 - Franchise And Excise Tax Intangible Expense Disclosure Form - Tennessee Department Of Revenue Form Rv-f1404701 - Franchise And Excise Tax Intangible Expense Disclosure Form - Tennessee Department Of Revenue Financial
Form Dr 7.3 - Affidavit Of Income, Expenses And Financial Disclosure Form - Court Of Common Pleas, Ohio Form Dr 7.3 - Affidavit Of Income, Expenses And Financial Disclosure Form - Court Of Common Pleas, Ohio Legal
Form 123 - Qme Or Ame Conflict Of Interest Disclosure Form - California Division Of Workers' Compensation Form 123 - Qme Or Ame Conflict Of Interest Disclosure Form - California Division Of Workers' Compensation Legal
Form D - Internal Fr Uniform Disclosure Form For Supervision And Regulation Personnel Form D - Internal Fr Uniform Disclosure Form For Supervision And Regulation Personnel Business

Related Categories

Parent category: Legal
Download
Go
Page of 2