PCC Criminal Background Check

PCC Criminal Background Check

PERMISSION TO CONDUCT BACKGROUND CHECK for VOLUNTEERS that WORK WITH CHILDREN or YOUTH AUTHORIZATION AT PORT COMMUNITY CHURCH.
I hereby authorize, without reservation, the obtaining of “consumer reports” or “investigative consumer” reports by PORT COMMUNITY CHURCH at any time after receipt of this authorization and throughout my employment or volunteer service, if applicable.

I further authorize and request, without reservation, any present or former employer, school, police department, state or federal agency, financial institution, division of motor vehicles, consumer reporting agencies, or other persons or agencies having knowledge about me to furnish a secure background check for Port Community Church with any and all background information in their possession regarding me, so that my employment qualifications may be evaluated and/or reassessed.

I also agree that a fax or photocopy of this authorization with my signature should have the same authority as the original.

By signing below, I certify: (1) that I have read and fully understand this disclosure and authorization; (2) that all of the information I am providing is true, complete, correct and accurate; and (3) that I have received the attached Summary of our Rights under the Fair Credit Reporting Act (15 U.S.C. §1681 et seq.).

The following is the information required in order for Port Community Church to obtain a complete consumer report.
Full Legal Name*

First NameMiddle NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
BIRTHDATE*
Month/Date/Year
SOCIAL SECURITY*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
OTHER OR FORMER NAMES (AKA, Maiden Names, Married Names, Surnames, Etc.)
The following are my responses to questions about my criminal record history (if any) with descriptions to any question with a YES answer:
1. Have you ever been convicted or plead guilty before a court of any federal, state, or municipal criminal offense? (Excluding minor traffic violations) *
NO or If YES, please explain
2. Have you ever received deferred adjudication or similar disposition for any federal, state or municipal criminal offense? *
NO or If YES, please explain
3. Have you ever received probation or community supervision for any federal, state or municipal criminal offense? *
NO or If YES, please explain
4. Have you ever been convicted of any criminal offense in a country outside the jurisdiction of the United States?*
NO or If YES, please explain
5. As of the date of this authorization, do you have any pending criminal charges against you? *
NO or If YES, please explain
6. Have you ever served in the US Military? *
NO or If YES, please explain
If you answered YES to the above question, did you receive a DD214?
If YES, can you present the document?:
If you answered YES to the above question 6, did you receive an honorable discharge?
If NO, please explain
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

PCC Criminal Background Check

The following are my responses to questions about my criminal record history (if any) with descriptions to any question with a YES answer: