Clearance for New Employees and New Volunteers

Clearance for New Employees and New Volunteers

(required whenever changing an employer or supervising entity)
Organization submitting this request
Name of employee or volunteer

First NameLast Name
Employee or volunteer's address
Street Address
Street Address 2
City
State
Zip
Employee or volunteer's address

Street Address

Street Address Line 2

CityState

Zip Code
Applicant is seeking clearance for employment or volunteer work? (Choose one)
Where will the individual be employed or volunteer?
YOUR name

First NameLast Name
YOUR title
Today's date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Email for receiving OPCY response
example@example.com
Postal address for hard copy
Street Address
Street Address 2
City
State
Zip
Postal Address for hard copy

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Should be Empty:

Employee or volunteer's address