Security Check Authorization Form (Employee)
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1YMCA of Northwest North Carolina
SECURITY CHECK AUTHORIZATION (EMPLOYEE)
DATE:
BRANCH:
DEPARTMENT:
POSITION:
NAME OF EMPLOYEE:_____________________________________________
New Hire
Re-hire
Volunteer
(Please Print Name)
SEX:
M
F
RACE:
White
Black/African American
Hispanic/Latino
Asian
Native Hawaiian/Other Pacific Islander
American Indian/Alaskan Native
2 or More Races
Starting with PRESENT ADDRESS, list all previous addresses and name(s) used at the address if different than above. Do
not use P. O. Boxes.
:______________________________________________________________________________________________________
ADDRESS
(Street)
(City, State & Zip)
(From/To)
(Name)
ADDRESS:_____________________________________________________________________________________________________
(Street)
(City, State & Zip)
(From/To)
(Name)
ADDRESS:_____________________________________________________________________________________________________
(Street)
(City, State & Zip)
(From/To)
(Name)
ADDRESS:_____________________________________________________________________________________________________
(Street)
(City, State & Zip)
(From/To)
(Name)
ADDRESS:_____________________________________________________________________________________________________
(Street)
(City, State & Zip)
(From/To)
(Name)
ADDRESS:_____________________________________________________________________________________________________
(Street)
(City, State & Zip)
(From/To)
(Name)
(If additional space is needed for address, please use a separate sheet of paper)
DATE OF BIRTH:________________SOCIAL SECURITY #:______________________________________
DRIVER’S LICENSE INFORMATION:________________________________________________________
(State and License Number)
"DISCLOSURE AND AUTHORIZATION: I understand that the YMCA may utilize the services of an outside agency to obtain a security
checks report, including a check of my criminal history, motor vehicle record, and social security number verification as part of the procedure
for processing my application for employment. I understand that before I am denied employment based on information obtained in the report, I
will be provided a copy of the report and a description in writing of my rights under the Fair Credit Reporting Act. I understand that if I
disagree with the accuracy of any information in the report, I must notify the YMCA within five days of my receipt of the report. If I notify the
YMCA within five days of the receipt of the report that I am challenging information in the report, the YMCA will not make a final decision on
my employment status until after I have had a reasonable opportunity to address the information contained in the report. Finally, I understand
that my employment with the YMCA is conditional based on the results of a criminal record check and MVR Report and that the YMCA has
sole discretion in making this decision. I acknowledge that I have been given a copy of the YMCA "Security Checks Policy" and understand
that I must abide by those guidelines at all times while employed by the YMCA."
__________________________________________
_________________
________________________________
(Signature of Applicant/Employee)
(Date)
(Applicant/Employee - Do Not Write Beyond This Line)
(THIS FORM SHOULD BE FAXED TO HUMAN RESOURCES PRIOR TO HIRING)
REQUEST MADE BY:________________________/____________
Criminal Check Only
MVR Only
Both
(Signature)
(Date)
____________________________________
(Print Name)
Revised: 03-2007
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