Church Background Check Form
Applicant Name
First Name
Middle Name
Last Name
Maiden Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Place of Birth
Gender
Male
Female
Other
Race
Driver's Security Number
State
Do you have a photo ID?
Yes
No
Emergency Contact Name
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Please list all counties and states of residence since the age of eighteen
Criminal History
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References
Have you ever been convicted or plead guilty before a court for any federal, state or municipal criminal offense? (Excluding minor traffic misdemeanors).
Yes
No
Please provide
State
County
Date of Offense
 -
Month
 -
Day
Year
Date
Details of Conviction
Have you ever received deferred adjudication or similar disposition for any federal, state or municipal offense?
Yes
No
Please provide
State
County
Date of Offense
 -
Month
 -
Day
Year
Date
Details of Conviction
Have you ever received probation or community supervision for any federal, state or municipal offense?
Yes
No
Please provide
State
County
Date of Offense
 -
Month
 -
Day
Year
Date
Details of Conviction
Have you ever been convicted of any criminal offense in a country outside of the jurisdiction of the United States?
Yes
No
Please provide
State
County
Date of Offense
 -
Month
 -
Day
Year
Date
Details of Conviction
As of the date of this consent form, do you have any pending charges against you?
Yes
No
Please provide
State
County
Date of Offense
 -
Month
 -
Day
Year
Date
Details of Conviction
Declaration
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I, the applicant, agree with the following statement:
I hereby certify that all the information that is provided in this consent form is true, correct and complete.
I understand all Offers of Employment / Volunteer are contingent upon the applicant's successful completion, as determined by the employer's sole discretion, of this criminal history / background check.
I do hereby consent to the church / division to use any information that is provided in this application to perform a criminal history check.
The church / division has informed me that I have the right to review and challenge any negative information that would adversely impact a decision to offer volunteer / employment work.
I have been informed that I will have a reasonable opportunity to clear up any mistaken information reported within a reasonable time frame established within the sole discretion of the church / division.
Under the Fair Credit Reporting Act, I have been advised that upon request I will be provided the name, address and phone number of the reporting agency as well as the nature, substance and source of all information.
Date
 -
Month
 -
Day
Year
Date
Signature of Applicant
Submit
Should be Empty: