Security Check Authorization Form (Volunteer)
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1YMCA of Northwest North Carolina
SECURITY CHECK AUTHORIZATION (VOLUNTEER)
DATE:
BRANCH:
DEPARTMENT:
POSITION:
NAME OF VOLUNTEER:_____________________________________________
SEX:
M
F
RACE:
White
Black
Hispanic
Native Am.
Asian
Other__________________________
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 Volunteer)
(Date)
(Volunteer - Do Not Write Beyond This Line)
(THIS FORM SHOULD BE FAXED TO HUMAN RESOURCES PRIOR TO ALLOWING APPLICANT TO VOLUNTEER)
REQUEST MADE BY:
___________________________________________________/____________________________
(Signature)
(Date)
___________________________________________________
(Print Name)
Revised 1/19/2011
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