Employee/volunteer Criminal Background Check Authorization printable pdf download

Catholic Diocese of Arlington

Employee/Volunteer Criminal Background Check Authorization

Please complete this form and return it to your employment/volunteer supervisor. A completed criminal

background history check is required for employment/volunteer service within all parishes, schools and other

organizations associated with the Catholic Diocese of Arlington.

The following information is to be completed by the prospective employee/volunteer.

Please print neatly. Write ‘N/A’ if not applicable – do not leave any blanks.

INCOMPLETE FORMS WILL BE RETURNED.

__________________________

____________

________________________________

First Name

Middle Initial

Last Name

__________________________

Sex: ⁮ Female ⁮ Male

______/___________/______________

Maiden Name/Aliases

Date of birth (MM/DD/YYYY)

Social Security Number: ____________________________ (if none, write “No SSN”)

Employment/Volunteer Location: __________________________________ ⁮ Parish ⁮ School ⁮ Other

Is this for a daycare or other childcare facility?

⁮ Yes ⁮ No

Employment/Volunteer Status:

⁮ Employee

⁮ Volunteer

Employee Job Title: ___________________________________

Volunteer Ministry:

⁮ Priest Volunteer

⁮ Religious Education

⁮ Youth Ministry

⁮ Scouts

⁮ Coach (volunteer only) ⁮ Other: _________________

Current Address__________________________________________________ Apt.#_________________

City_____________________________________________ State: _______ Zip: _______________

How many years have you lived in Virginia?_________________

List all prior states of residence: ___________________________________________________

I hereby give my permission for the Diocese of Arlington to obtain information relating to my criminal history record. I

understand that as long as I remain an employee or volunteer, the Criminal History Records check may be repeated at

any time. I understand that I will have an opportunity to review the Criminal History and a procedure is available for

clarification, if I dispute the record as received.

I, the undersigned, do, for myself, my heirs, executors hereby release and forever discharge the Diocese of Arlington and

each of its officers, employees, and agents from and against any and all causes of action, charges, liabilities, claims

including court costs, expenses and attorneys fees, resulting from the investigation of my background in connection to

my employment/volunteer assignment with the Diocese of Arlington.

____________________________________

________________________

Applicant’s Signature

Date

Employee/volunteer Criminal Background Check Authorization

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