Shepherd of the Bay Lutheran Church
Ellison Bay, WI
NOTICE/AUTHORIZATION AND RELEASE FOR THE PROCUREMENT OF AN INVESTIGATIVE REPORT
I ________________________________________, hereby authorize The Shepherd of the Bay Lutheran Church to have the following background check screening report processed through the agency or insurance company contracted by the church and/or its agent or its agent or representative for employment or volunteer purposes: Application Verification, National Criminal Report, Sexual Abuse Registry and County Court Report.
I am aware that this background check is only a screening tool and I may be asked to provide additional information or my fingerprints to resolve issues discovered during the screening.
I am aware that the background check screening report I consent to have prepared may include information obtained from a variety of sources, including but not limited to government agencies and others. I am aware that if I choose, I may obtain a complete disclosure of the nature and scope of any report prepared about me if I make a written request to The Shepherd of the Bay Lutheran Church council president within a reasonable time after I execute this authorization.
I understand that a photocopy or facsimile of this signed document shall be considered as valid as an original.
PLEASE PRINT CLEARLY
Full Name:_____________________________________ Social Security No. _______-____-_________
All other names that have been used (i.e. Maiden Name) _______________________________________
Address: _____________________________________________ Date of Birth: ____/____/_________
City/State/Zip code: __________________________________________ County: _________________
Previous address if less than 10 years: ______________________________________________________
City/State/Zip code: _________________________________________ County: __________________
Drivers License No: ____________________________________ State of Issuance: ________________
Gender: Female _____ Male _____ E-mail_______________________________________
________________________ _________________________________________________
Date Applicant’s Signature
By submitting this application: You understand that if the background check identifies a pending adjudication or conviction for any proscribed offense(s), child contact or driving approval by The Shepherd of the Bay Lutheran Church will be withheld or revoked. You acknowledge that The Shepherd of the Bay Lutheran Church may withhold, suspend or revoke a credential if you have ever, as an adult or a juvenile, been convicted, adjudicated or placed on term of probation or parole for any felony-level crime or offense. You hereby consent to the release by The Pastor of the fact of your approval or non-approval by The Shepherd of the Bay Lutheran Church. You hereby release the contracted agency, as custodian of such records, and such agency employees or personnel, both individually and collectively, from any and all liability for damages of whatever kind, which may at any time result to you, your heirs or assigns, family or associates because of compliance with or release of information pursuant to this authorization, except in the case of gross negligence. You acknowledge that you have read the foregoing release, understand it and agree to the terms and conditions therein. ___________ initialed
Ellison Bay, WI
NOTICE/AUTHORIZATION AND RELEASE FOR THE PROCUREMENT OF AN INVESTIGATIVE REPORT
I ________________________________________, hereby authorize The Shepherd of the Bay Lutheran Church to have the following background check screening report processed through the agency or insurance company contracted by the church and/or its agent or its agent or representative for employment or volunteer purposes: Application Verification, National Criminal Report, Sexual Abuse Registry and County Court Report.
I am aware that this background check is only a screening tool and I may be asked to provide additional information or my fingerprints to resolve issues discovered during the screening.
I am aware that the background check screening report I consent to have prepared may include information obtained from a variety of sources, including but not limited to government agencies and others. I am aware that if I choose, I may obtain a complete disclosure of the nature and scope of any report prepared about me if I make a written request to The Shepherd of the Bay Lutheran Church council president within a reasonable time after I execute this authorization.
I understand that a photocopy or facsimile of this signed document shall be considered as valid as an original.
PLEASE PRINT CLEARLY
Full Name:_____________________________________ Social Security No. _______-____-_________
All other names that have been used (i.e. Maiden Name) _______________________________________
Address: _____________________________________________ Date of Birth: ____/____/_________
City/State/Zip code: __________________________________________ County: _________________
Previous address if less than 10 years: ______________________________________________________
City/State/Zip code: _________________________________________ County: __________________
Drivers License No: ____________________________________ State of Issuance: ________________
Gender: Female _____ Male _____ E-mail_______________________________________
________________________ _________________________________________________
Date Applicant’s Signature
By submitting this application: You understand that if the background check identifies a pending adjudication or conviction for any proscribed offense(s), child contact or driving approval by The Shepherd of the Bay Lutheran Church will be withheld or revoked. You acknowledge that The Shepherd of the Bay Lutheran Church may withhold, suspend or revoke a credential if you have ever, as an adult or a juvenile, been convicted, adjudicated or placed on term of probation or parole for any felony-level crime or offense. You hereby consent to the release by The Pastor of the fact of your approval or non-approval by The Shepherd of the Bay Lutheran Church. You hereby release the contracted agency, as custodian of such records, and such agency employees or personnel, both individually and collectively, from any and all liability for damages of whatever kind, which may at any time result to you, your heirs or assigns, family or associates because of compliance with or release of information pursuant to this authorization, except in the case of gross negligence. You acknowledge that you have read the foregoing release, understand it and agree to the terms and conditions therein. ___________ initialed