Ymca Of Greater Cleveland Application Form Page 6
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6Revised 5/2012
YMCA of
Greater Cleveland
EQUAL OPPORTUNITY EMPLOYER
This application will remain active for 30 days.
VOLUNTEER APPLICATION
DISCLOSURE AND AUTHORIZATION TO BACKGROUND INVESTIGATION
PURSUANT TO THE FAIR CREDIT REPORTING ACT
DISCLOSURE
As an applicant for a position with the YMCA of Greater Cleveland, you have been asked to furnish information
for use in reviewing your background and qualifications. As part of its investigation and consideration of your
application, the YMCA of Greater Cleveland may obtain a consumer report from a Consumer Reporting Agency
which may include information about your background, including your past and present work, character, educa-
tion, military records, court records and criminal records. Before the YMCA of Greater Cleveland takes any adverse
action based in whole, or in part, on a consumer report from a Consumer Reporting Agency, it will provide you a copy
of that report and will give you a written description of your rights under the Fair Credit Reporting Act.
AUTHORIZATION
I hereby authorize the YMCA of Greater Cleveland, or any of its agents, to conduct an investigation of my back-
ground and qualifications. I authorize the release of any information pertaining to my background and qualifica-
tions, including those categories of information listed above, whether the information is of public record or not.
I hereby authorize and instruct any Consumer Reporting Agency to provide a consumer report to the YMCA of
Greater Cleveland if it should make such a request.
This authorization shall remain effective for any future investigations by the YMCA of Greater Cleveland.
By typing my first and last name followed by the last four digits of my Social Security Number, I hereby authorize this form.
SIGNATURE:
SOCIAL SECURITY NUMBER:
PRINT NAME:
DATE:
PARENT/GUARDIAN SIGNATURE:
DATE OF BIRTH:
**Applicants under the age of eighteen (18) must have signed approval from a parent or guardian.
Return this form completed at the time of interview.
Do not write below this line.
To:
Human Resources Department
From:
BRANCH NAME:
SENDER:
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