Safe Environment Applicant Information For Live Scan Form
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1***NOT A LIVE SCAN FORM*****NOT A LIVE SCAN FORM*****NOT A LIVE SCAN FORM***
Safe Environment Applicant Information
For Live Scan Form
School/Parish:_
_
Application Type
Employee
Volunteer
(Circle One)
Job Title (circle one below)
Volunteer Catechist
Catholic School Teacher
Administrator
General Staff Member
Volunteer with Supervisor
Volunteer
Duties
Multiple jobs/positions
Other
Personal Information
Telephone:___________________
First Name:_
Last Name:_
Alias:_
Drivers License #:_
SSN#:_
Date of Birth:_
Place of Birth:_
Physical Information
Height:_
Hair Color:_
Weight:_
Eye Color:_
Sex
Male
Female
(Circle One)
Home Address
Street:_
City:_
State:_
Zip:_
Check all that apply:
I will be working with children
I will be working with money
I will be driving a vehicle in the course of my
volunteer/employee duties
***NOT A LIVE SCAN FORM*****NOT A LIVE SCAN FORM*****NOT A LIVE SCAN FORM***
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Parent category: Life