Background Check Consent

Background Check Consent Form

Please note: This form is encrypted upon submission for the safety of your personal information.
The following information is required to run a national background check and must be completed in its entirety.
Last Name*
First Name*
Middle Name
Leave blank if no legal middle name
Name Suffix
Date of Birth*

MonthDayYear
Date
SSN*
No dashes or separators
Present Address/Physical Address:

Please list Physical Address if different from Mailing Address
Street Number
Street Name
Apt #
City*
State*
Zip*
Gender*

MaleFemale
I hereby authorize Illinois Student Ministries/and/or its agents to make an independent investigation of my background, references, character, past employment, education, criminal or police records, including those maintained by both public and private organizations and all public records for confirming the information contained on my application and/or obtaining other information which may be material to my qualifications for volunteering for counselor/staff at the Illinois Student Ministries Event for which I am applying. I release Illinois Student Ministries and/or its agents and any person or entity, which provides information pursuant to this authorization, from any and all liabilities, claims or lawsuits in regards to the information obtained from any and all of the above-referenced sources used. The information submitted in step one of this form is my true and legal name and all information is true and correct to the best of my knowledge.
Please check the following and sign below:*

I agree to the above and give Illinois Student Ministries, a department of the Illinois District of the Assemblies of God, permission to perform my national background check.
Signature*

Clear
Should be Empty:

Background Check Consent Form