Background Check Information and Release Form

Background Check Information and Release Form
Full name: First, middle, last, name suffix
Example: Susan Marie Wilson, Sr.
Other last names used
Other First Names Used
Social Security Number
Was this Social Security Number issued after June 2011: Yes or No
Gender
Date of Birth

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Driver's license number and two-character abbreviation for state issuing license
Example: 777888999 NY
Home church
District within Upper New York Conference
Purpose for Background Check Request

Other
State full name for the Waiver and Consent:
First, middle, last, name suffix
Signature
Date

MonthDayYear
Have you ever been charged, convicted of or pled guilty to a crime, either misdemeanor or felony (including but not limited to: drug-related charges, child abuse, other crimes of violence, theft or motor vehicle violations)? Please state all, even if you don't believe they will appear on your record.
If you answered "yes" to the above question, please explain.
Have you ever had an Order of Protection or comparable civil or criminal order issued against you?
If you answered "yes" to the above question, please explain.
I have lived at other addresses within the past 10 years.
If you answered "Yes" above, please list ALL previous addresses where you have resided during the past 10 years.
For example, 1. 123 Main St., Anytown, NY 12345; 2. 777 Temple Ct., Jerusalem, NY 12345; etc.
Should be Empty: