Release of Information

RELEASE OF INFORMATION

Texas Ministries of the Church of God

Full Name *

First Name Middle Name Last Name

Date of Birth *

Email *

example@example.com

Phone Number *

Area Code Phone Number

Please read the statement below, and write your signature on the line to show that you have read and agree to it.

I hereby authorize the Texas Ministries of the Church of God (TXM) to request, receive, maintain, and transfer upon request any and all investigative reports, applications, letters, references, forms, and any other information in regards to my licensing, ordination, and ministerial services. I understand that some of these reports could contain information about my character, general reputation, personal characteristics, and mode of living, as well as information related to my criminal history, credit history, driving and motor vehicle records, education, employment history, or other background checks. I further authorize the TXM to keep all information received as part of my professional file. I understand this file is considered permanent and is transferable to another authority within the Church of God assembly.

Printed Name *

Date Signed *