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Background Check Authorization
Name
*
First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Have you ever been known by any other name?
*
Please Select
Yes
No
If yes, please provide the name.
Notice
Upon request, you will be informed whether or not a background report was requested by the Company, and if such report was requested, informed of the name and address of the reporting agency that furnished the report. You have the right to inspect and receive a copy of any investigative consumer report requested by the Company contacting the reporting agency identified above. By signing below, you acknowledge receipt of Article 23-A of the New York Correction Law.
Email of Church / Committee Requesting Results
*
example@example.com
Name of Church or HRP Committee requesting the background check:
*
Please send results to:
*
First Name
Last Name
Email of Recipient
*
example@example.com
I understand that this background check will be conducted by an independent investigative firm and will be paid for by:
*
Please Select
The Church / Employer
Myself (i.e. For those on the Pulpit Supply List)
The Presbytery of Hudson River
Note
(If you or the Session/Council believe this presents an undue financial hardship, you or the Clerk of Session/Council may request Presbytery funds to cover the cost of the background check by contacting the General Presbyter.)
Authorization / Release
I understand and authorize that a background review shall be conducted with respect to the information provided on my Background Check Authorization. I attest that all the information provided on the Background Check Authorization is truthful. This review will include a criminal history background check and a review of the sexual offender's registry. I understand that the results of this review may be used to determine my suitability for a call and/or employment within the Presbytery. I hereby release from liability and damages the Presbytery of Hudson River and its agents who conduct or participate in such a review, as well as those individuals, organizations, and their agent(s) who provide information during this process, provided such information is released without malicious intent. I further authorize all such persons and entities to accept a photocopy of this Authorization as if it were the original executed document.
Today's Date
*
-
Month
-
Day
Year
Date
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Social Security Number
*
Date of Birth
*
-
Month
-
Day
Year
Date
Name
*
First Name
Last Name
Signature
*
Please verify that you are human
*
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Submit
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