Background Check Authorization Form

I, enter name* Hereby authorize Calvary Chapel Grants Pass to have the following background check screening reports processed through the agency contacted by the church and/or its agent or representative for employment or volunteer purposes.

I am aware that this background check is only a screening tool and I may be asked to provide additional information to resolve issues discovered during the screening.

I am aware that the background check screening report I consent to have prepared may include information obtained from a variety of sources, including but not limited to government agencies, and others. I am aware that if I choose, I may obtain a complete disclosure of the nature and scope of any report prepared about me if I make a written request to Calvary Chapel Grants Pass within a reasonable time after I execute this authorization.

I understand that a photocopy or facsimile of this signed document shall be considered as valid as an original.

Full Name*

First NameMiddle NameLast Name

Social Security #*

Driver's License #*

All other names that have been used (e.g. Maiden Name, Alias, etc.)

Address*

Street Address

Street Address Line 2

CityState

Zip Code

Date of Birth*

Date

Gender*

Signature*

Date of Signing*

Date

By submitting this application: You understand that if the background check identifies a pending adjudication or conviction for any proscribed offense(s), volunteer or employment approval may be withheld or revoked. You acknowledge that [Calvary Chapel Grants Pass] may withhold, suspend, or revoke a credential if you have ever, as an adult or a juvenile, been convicted, adjudicated or placed on term of probation or parole for any felony-level crime or offense. You hereby consent to the release by [Calvary Chapel Grants Pass] of the fact of your approval or non-approval by [Calvary Chapel Grants Pass]. You hereby release the contracted agency, as custodian of such records, and such agency employees or personnel, both individually and collectively, from any, and all liability for damages of whatever kind, which may at any time result to you, your heirs or assigns, family or associates because of compliance with or release of information pursuant to this authorization, except in the case of gross negligence. You acknowledge that you have read the foregoing release, understand it and agree to the terms and conditions therein.