Temple Baptist Church Background Check

ROD HOWELL • COLQUITT COUNTY
200 VETERANS PKWY N/ P.O. BOX 188
MOULTRIE, GEORGIA 31776-0188
(229) 616-7430 • (229) 616-7436
REQUEST FOR DISSEMINATION OF RECORDS AND INFORMATIONINDIVIDUAL'S CONSENT
(Pursuant to O.C.G.A. 35-3-34 & O.C.G.A. 35-3-35)
*I, the undersigned, hereby authorize Temple Baptist Church of Colquitt County, Inc. to receive any criminal history record information pertaining to me which may be in the files of any state or local criminal justice agency in Georgia.
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REQUESTOR'S ACKNOWLEDGEMENT
DISCLOSURE PROVISION: IN THE EVENT THAT AN EMPLOYMENT OR LICENSING DECISION IS MADE ADVERSE TO THE PERSON ABOVE, THE PERSON MUST BE INFORMED, BY THE INDIVIDUAL OR GROUP MAKING THE DECISION, OF ALL PERTINENT INFORMATION WHICH RESULTED IN THE ADVERSE DECISION. THIS DISCLOSURE SHALL INCLUDE INFORMATION THAT A RECORD WAS OBTAINED, THE SPECIFIC CONTENTS OF THE RECORD, AND THE EFFECT THE RECORD HAD UPON THE DECISION. FAILURE TO PROVIDE ALL SUCH INFORMATION TO THIS PERSON SHALL BE A MISDEMEANOR.
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REQUEST FOR DISSEMINATION OF RECORDS AND INFORMATIONINDIVIDUAL'S CONSENT