Notarized Criminal Background Statement Form - South Carolina Annual Conference Board Of Ordained Ministry
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1SOUTH CAROLINA ANNUAL CONFERENCE Board of Ordained Ministry
NOTARIZED CRIMINAL BACKGROUND STATEMENT
(Par. 310.2b, 315.16, and 324.12) Please Print or type this form
Name:______________________________________________________________________________
Street Address
Date of Birth: _______________________________ Social Security No. _________________________
Have you ever been convicted of a felony? _____ Yes _____No.
Have you ever been accused of a felony? _____ Yes _____No.
If “Yes” state in detail the nature of the conviction or accusation.
Have you ever been convicted of a misdemeanor? _____ Yes _____ No.
Have you ever been accused of a misdemeanor?
_____ Yes _____ No.
If “Yes”, please state in detail the nature of the conviction or accusation.
Have you ever been convicted of sexual misconduct? _____ Yes _____ No.
Have you ever been accused of sexual misconduct?
_____ Yes _____ No.
If “Yes”, please state in detail the nature of the conviction or accusation.
I ________________________________________________, Affirm that all the information provided by me on this
form is true, correct and accurate.
I understand that if false information has been given, my application process in the South Carolina Annual
Conference of the United Methodist Church will be terminated, and I will be subject to any disciplinary actions as set
forth by said Annual Conference. By signing this I further grant permission for The Board of Ordained Ministry to
conduct Criminal Background Investigations whenever needed.
“A past felony conviction is not an absolute bar to employments with the South Carolina Annual Conference
of the United Methodist Church. It is our policy to consider: 1) The nature and gravity of the offense or conduct; 2)
The time that has passed since the offense, conduct and/or completion of the sentence; and 3) The nature of the job
held or sought. It is also our policy to use individualized assessments to consider more complete information to
determine whether exclusions based on past criminal conduct are job related and consistent with business
necessity.”
Signature: ___________________________________
Date: _________________________
Notary Public Signature & Seal
State of South Carolina, County of _____________________________
Sworn before me on this ____________________________
________________________________________________________________________
Notary Public of The State of South Carolina
My commission expires _____________________________
Please Send this form and the remittance fee ($18.00) payable to SC Conference Treasurer to:
Office of Clergy Services, 4908 Colonial Drive, Columbia, SC 29203 or go online to pay at
(scroll down to Candidacy
Forms then to 07SCBOM Criminal Background Consent – Click here to pay for background check)
Copy distribution: DS-Office; Mail original with seals to Clergy Services, 4908 Colonial Dr. Columbia, SC 29203)
Revised 1/9/15
07SCBOM-SLED
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