PCC Criminal Background Check

Port Community Church Safe Church Plan Yearly Review & Criminal Back Ground Check

All Trustees, members of the Church Council, employees, and ministry volunteers of Port Community Church are required to read the Safe Church Plan along with all subsequent updates. This document can be obtained from the church office or accessed on the church website (password required). Thank you for your helpful cooperation. If you have any questions, please contact the church office.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
This must be done on a yearly basis:
My signature indicates that I fully understand and will follow the Safe Church Plan and Code of Conduct of Port Community Church.
TODAY's DATE:

MonthDayYear
Date
Do you need to complete the Background Check Information?

CRIMINAL BACKGROUND CHECK AUTHORIZATION

A Criminal Background Check will be completed every three years.
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.Format: (000) 000-0000.
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
Date

MonthDayYear
Date
Should be Empty:

Port Community Church Safe Church Plan Yearly Review & Criminal Back Ground Check

CRIMINAL BACKGROUND CHECK AUTHORIZATION

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