Background Check Application - Diocese Of Scranton, Pa
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1Revision 61315
Diocese of Scranton
Background Check Application
In accordance with the Charter for the Protection of Children and Young People and the Pennsylvania Child
Protective Services Laws, the Diocese of Scranton conducts background clearances EVERY 36 MONTHS on all
individuals who have direct contact or routine interaction with children. The purpose of this application is to authorize the
Safe Environment Office to complete a State Police Criminal History Check. Once processed, the clearance results will
be sent to the applicant along with instructions on completing additional required background checks.
Please Print Clearly
FIRST NAME - Subject of Record Check
MIDDLE NAME
LAST NAME
Address
City
State
Zip Code
Phone Number:
Have you resided continuously in PA for the past 10 years?
(
)
_______ Yes
_______ No
E-mail Address:
Maiden Name and/or Aliases
Social Security Number
Date of Birth
Gender:
Race
____ Female
____ Male
Name of Parish/School where Background Check is Needed:
________________________________________________________________________________________________
Town:___________________________________________________________________________________________
This Background Check is needed because you are:
(Please indicate your status)
_____ Parish Employee
_____ Parish Volunteer
_____ Diocesan Employee
_____ Clergy
_____ Deacon
_____ Religious Order
_____ Applicant for Formation
_____ School Volunteer
Other ______________________________________________
Name of Organization or Entity
Applicant Signature: ____________________________________________
Date: __________________
Effective 7/25/15, there is no cost for state clearances for volunteers.
Effective 7/25/15, cost for Employees is $8.00 per applicant.
Please make check or money order payable to Diocese of Scranton.
Mail to:
Diocese of Scranton
ATTN Kathy Bolinski
300 Wyoming Avenue
Scranton, PA 18503
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