Crime Stoppers Advisory Board Application

GREATER SPRINGFIELD AREA CRIME STOPPERS

Advisory Board Application
Full Legal Name (first, middle and last): *
I do hereby authorize a review and full disclosure of all records concerning myself to any duly authorized officer of the City of Springfield, Missouri, and its Police Department, whether the said records are of public, private, or confidential nature.

The intent of this authorization is to give my consent for full and complete disclosure of traffic and criminal history records, and records involving any incident where I have been arrested or convicted of a crime. The records referred to in this paragraph shall include, but are not limited to, papers, documents, recordings and photographs, whether on paper or stored/transmitted electronically. I understand that any information obtained by a personal history background investigation which is developed directly or indirectly, in whole or in part, upon this release authorization, may be considered in determining my suitability for membership on the Greater Springfield Area Crime Stoppers Advisory Board, an unpaid, voluntary position. I understand that such information will not be used for any purpose other than for consideration of the above as a volunteer for the Greater Springfield Area Crime Stoppers Advisory Board, and this background check is required because of the nature of the particular position that I have made application to in that it involves sensitive information and is in an area where confidentiality and security is important. I also certify that any person(s) who may furnish such information concerning me shall not be held accountable for giving this information; and I do hereby release said person(s) from any and all liability which may be incurred as a result of furnishing such information. I further release any City of Springfield, Missouri, employee who conducts any part of my background investigation from any and all liability resulting from such investigation.
Signature:*

Clear
Date:*

MonthDayYear
Date
Failure to fill out this form clearly, correctly and completely may eliminate the applicant from further consideration and could result in civil or criminal penalties.
Personal Information
Prefix
Legal Name:*

First NameLast Name
Maiden Name (if applicable):
Current Home Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Previous Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please list any other states you've lived in and rough timeline (i.e. MO June 2012-May 2018):
Gender Pronouns*
Race/Ethnicity: *
Other:
Date of Birth:*

MonthDayYear
Date
ID or Driver’s License Number:*
Please list state where ID was issued:*
Cell Number:*

Area CodePhone Number
Home Number:

Area CodePhone Number
Email Address:*
example@example.com
Employer Name:*
Title/Position:*
Length of Employment:*
Employer Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Work Number:*

Area CodePhone Number
Please explain why you are interested in becoming a Crime Stoppers Board Member. *
Please describe any other community involvement- past or present.*
Please list any skills or strengths you feel would be beneficial to the board should you be appointed.*
Please provide a brief criminal history, if applicable:
Do you feel that you would be able to attend a Crime Stoppers Advisory Board Meeting at least once a month?*

YesNoUnsure
Are you willing to devote a small amount of time each month to Crime Stoppers activities, outside of regular meetings (i.e. fundraising/community events)?*

YesNoUnsure
Personal References:
Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Confidentiality and Non-Disclosure Agreement:
Date:*

MonthDayYear
Date
Whereas, Greater Springfield Area Crime Stoppers agrees to furnish you, as a member of the Advisory Board, certain confidential information relating to criminal activity in the Greater Southwest Missouri area for the purposes of determining awards to individuals;

Whereas, you as a member of the Advisory Board agree to review, examine, inspect, or obtain such confidential information only for the purposes described above, and to otherwise hold such information confidential pursuant to the terms of this agreement.
Legal Name*

First NameLast Name
agrees to hold confidential or proprietary information discussed during a Crime Stoppers board meeting or other venture involving Crime Stoppers in trust and confidence and agree that it shall be used only for the contemplated purposes, shall not be used for any other purpose, or disclosed to any third party.

No copies will be made or retained, of any written information supplied without the express permission of Greater Springfield Area Crime Stoppers.

At the conclusion of any discussion, or upon demand by Greater Springfield Area Crime Stoppers, all confidential information shall be returned to the Crime Stoppers Coordinator.

This agreement and its validity, construction, and effect shall be governed by the laws of the State of Missouri.
Signature:*

Clear
Should be Empty:

GREATER SPRINGFIELD AREA CRIME STOPPERS

Personal Information

Personal References:

Confidentiality and Non-Disclosure Agreement: