Northminster Presbyterian Church Employment Application/criminal History Background Check & Driver'S License Authorization Form Page 4
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RIMINAL
ISTORY
ACKGROUND
HECK
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& D
L
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F
RIVER
S
ICENSE
UTHORIZATION
ORM
Northminster Presbyterian Church requires criminal background checks of all full-time and part-time applicants, employees,
interns and volunteers (over age 18). These measures are being instituted in an attempt to ensure the safety of participants,
employees and volunteers.
APPLICANT OR EMPLOYEE INFORMATION
PLEASE PRINT CLEARLY
Employee
Volunteer
O Applicant
Status:
Last
First
Middle
Name:
Name:
Initial:
If you may be known by any other name (i.e., pre-marriage, alias), please indicate: Yes No
If so, when was the last year you used this name?
Other Last
Other First
Other Middle
Name:
Name:
Initial:
Other Last
Other First
Name:
Name:
Other
Middle
Initial:
I certify that the information provided above is true and complete. I understand that false or misleading information
given in my employment or volunteer application, interview(s) or on this form will render my application void and
will result in termination in the event of my employment or volunteer assignment.
I authorize Northminster
Presbyterian Church to make a criminal background investigation in arriving at a decision regarding my
employment or volunteer service. I further authorize the Illinois State Police to release criminal background
information as part of the criminal background .
Signature:
Date:
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