Release of Information

Name*

FIRSTLAST

Date of Birth*

Email*

example@example.com

Primary Phone*

Primary Phone Kind:*

MobileWorkHomeOther

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 reports, applications, letters, references, forms, and any other information in regard to my licensing, ordination, and ministerial services. I understand that some of these reports could contain information about my character, general reputation, personal characteristics, 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 will be retained in secure, confidential file and will be made available only to authorized personnel in the state and national Church of God Ministries office, and in the event of transferring credentials to another Church of God Assembly the transferring state's assembly credentials office. Electronically sign your name or initials below.*

Date Signed*

Date Signed:*

Date