Background Check Permission Form
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1Recreation Ministry
Position/sport:__________________
BACKGROUND CHECK PERMISSION FORM
Please write NEATLY
The following is identifying information for the Background Information Agency (also known as “Consumer Reporting Agency”).
Name (Last)
___
_____ (First) ___________
_ (Middle) ______________________
Generation (Jr., Sr., etc).__________ List any maiden/other name used in the last 7 years
______________________
Social Security Number: __________-______-___________
Driver’s License # ___________________________
State____
Expiration date:_______________
Date of Birth:
__
/
/ 19 ____ Home Phone (_______)______________
Gender:___Male ___Female
Current Street Address:_______________________________________ City
____
State
Zip_______
Dates at this address:
/
to
/
.
Other addresses where you have lived in the past 7 years:
Address #2
_______________________________________________ City
____
State
Zip_______
Dates
/
to
/
.
Address #3 _ _______________________________________________ City
____
State
Zip_______
Dates
/
to
/
.
Address #4 _ _______________________________________________ City
____
State
Zip_______
Dates
/
to
/
.
Permission to Obtain a Background Check
(This form authorizes the church to obtain background information and must be completed by the applicant. The church
must keep this completed form on file for at least five years after requesting a background check.)
I, the undersigned applicant (also known as “consumer”), authorize Christ United Methodist Church through its
independent contractor, LexisNexis, and /or Bonzi, to procure background information (also known as a “consumer
report and/or investigative consumer report”) about me. This report may include my driving history, including any
traffic citations; Social Security Number verification; driver’s license verification; present and former addresses; criminal
and civil history records; and sex offender records.
I understand that I am entitled to a complete copy of any background information report of which I am subject
upon my request to Christ United Methodist Church, if such is made within a reasonable time from the date it was
produced. I also understand that I may receive a written summary of my rights under the
Fair Credit Reporting Act.
Applicant Signature:
_____________
Today’s Date:
/
/
.
Ministry Approval:
_____________
Budget Code:
REC
.
Signature
(Ministry Budget)
Revised: January 2013
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