Employee/volunteer Criminal Background Check Authorization


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.
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 Job Title: ___________________________________
Volunteer Ministry:
 Priest Volunteer
 Religious Education
 Youth Ministry
 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


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