Background Check

I am applying to work in the following area(s)

ChildrenYouthSecurity Team/Lead Usher

AUTHORIZATION OF BACKGROUND INVESTIGATION

I hereby authorize True North Church to obtain and/or request information about my criminal history and fingerprints from any entity chosen specifically for conducting this search, to release information regarding any record of charges or convictions contained in its files, or in any criminal file maintained on me, whether said file is a local, state, or national file, and including but not limited to accusations and convictions for crimes committed against minors, to the fullest extent permitted by city, county, state, or federal law. I do release said entities from all liability that may result from any such disclosure made in response to this request. I may revoke this request at any time, but that revocation must be in writing and give 30 days’ notice of same.

First Name*

Middle Name*

Last Name*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number*

Area CodePhone Number

Date of Birth*

MonthDayYear

SSN*

Driver's License #

State of License

E-mail*

Have you ever been convicted of or pleaded guilty to a crime?*

YesNo

If yes, please explain

(Not relatives or former employers)

Reference #1*

First NameLast Name

E-mail Reference #1*

Phone Reference #1*

Area CodePhone Number

Reference #2*

First NameLast Name

E-mail Reference #2*

Phone Reference #2*

Area CodePhone Number

Applicant’s Statement

The information contained in this application is correct to the best of my knowledge. I authorize any references or churches listed in this application to give any information (including opinions) that they may have regarding my character and fitness for children or youth work. In consideration of the receipt and evaluation of this application, I hereby release any individual, church, youth organization, charity, employer, reference, district, camp, or any other person or organization, including record custodians, both collectively and individually, from any and all liability for damages of whatever kind or nature which may at any time result to me, my heirs, or family, on account of compliance or any attempts to comply, with this authorization. I waive any right that I may have to inspect any information provided about me by any person or organization identified by me in this application.

Should my application be accepted, I agree to be bound by the Bylaws and policies of the church/Network and to refrain from unscriptural conduct in the performance of my service on behalf of the church/Network.

I further state that I HAVE CAREFULLY READ THE FOREGOING RELEASE AND KNOW THE CONTENTS THEREOF, AND I SIGN THIS RELEASE AS MY OWN FREE ACT. This is a legally binding agreement which I have read and understand.

By typing your initials below, you are signing this form.

Initials*

Date*

MonthDayYear

Background Check

AUTHORIZATION OF BACKGROUND INVESTIGATION

Personal References