Background Check Release Form Disclosure And Authorization


Background Release Form
Disclosure and Authorization
In connection with my application for employment or current employment (including contract for service) with
_________________________________________________ (“the Company” a church or extension ministry
appointed by the Bishop of the California-Pacific Annual Conference), I understand that investigative inquiries may be
obtained on myself by a consumer reporting agency, and that any such report will be used solely for employment-
related purposes. I understand that the nature and scope of this investigation will include a number of sources
including, but not limited to, consumer credit, criminal convictions, motor vehicle, and other reports. These reports
will include information as to my character, general reputation, personal characteristics, mode of living, and work
habits. Information relating to my performance and experience, along with reasons for termination of past
employment from previous employers, may also be obtained. Further, I understand that you will be requesting
information from Federal, State, County and other agencies that maintain records concerning my past activities relating
to my driving, credit, criminal, civil, education, and other experiences.
I understand that if the Company hires me, it may request a consumer report or an investigative consumer report about
me for employment-related purposes during the course of my employment. The scope of this investigation will be the
same as the scope of a pre-employment investigation, and that the nature of such an investigation will be my
continuing suitability for employment, or whether I possess the minimum qualifications necessary for promotion or
transfer to another position. I understand that my consent will apply throughout my employment, unless I revoke or
cancel my consent by sending a signed letter or statement to the Company at any time, stating that I revoke my consent
and no longer allow the Company to obtain consumer or investigative consumer reports about me.
I understand that I am being given a copy of the “Summary of Your Rights Under the Fair Credit Reporting Act”
prepared pursuant to 15 U.S.C. Section 1681-1681u. If I am applying for employment in the State of California or if I
am a resident of California at the time of applying for employment, a summary of the provisions of California Civil
Code section 1786.22 is also being provided to me with this form.
This Disclosure and Authorization form, in original, faxed, photocopied or electronic form, will be valid for any
reports that may be requested by the Company. A copy of the completed report will be mailed to you.
I authorize without reservation any party or agency contacted by this employer to furnish the above-mentioned
information. I hereby consent to your obtaining the above information from Accurate Background, Inc. (and/or any of
their licensed agents) located at 6 Orchard, Suite 200, Lake Forest, CA 92630, (800) 784-3911,
I understand that I may view the privacy policy at
I understand to aid in the proper identification of my
file or records the following personal identifiers, as well as other information, is necessary.
Print Name ________________________________________________________________________________
Other Names Known By _____________________________________________________________________
Social Security Number ______ - ______ - ______
Date of Birth _____/ _____/ _____
Driver License Number ______________________________ State _______________
Current Address ____________________________________________________________________________
City _______________________________________________State ______________ Zip ________________
Telephone Number ___________________________ E-Mail Address _________________________________
Applicant Signature____________________________________________ Date _________________________
Prospective or current Employer ________________________________________________________________
(Church or Extension Ministry)
Please return Background Release Form to: Lillian Figueroa, HR Dept., Cal-Pac Annual Conference of UMC
PO Box 6006. Pasadena, CA 91102-6006,
Phone #: (626) 568-7341, Fax #: (626) 568-7340
CA applicants: I would like to receive a copy of any report obtained on me by “the Company.” □ Yes
□ No


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