Permission to Obtain a Background Check

(This form authorizes the church to obtain background information and must be completed by the applicant.  
The church must keep this completed form on file for at least five years after requesting a background check.)

  insert church name

In the interest of safety and security I, the undersigned applicant (also known as “consumer”), authorize _______________________ through its independent contractor, First Advantage, to procure background information (also known as a “consumer report and/or investigative consumer report”) about me, prior to, and at any time during, my service to the organization.  This report may include my driving history, including any traffic citations; a social security number verification; present and former addresses; criminal and civil history/records; and the state sex offender records. 

insert church name

I understand that I am entitled to a complete copy of any background information report of which I am the subject upon my request to _________________________________, if such is made within a reasonable time from the date it was produced.  I               
also understand that I may receive a written summary of my rights under the Fair Credit Reporting Act.

Signature:  ________________________________________________	Date:  ___________________________________

Identifying Information for Background Information Agency 
(also known as “Consumer Reporting Agency”)

Print Name:  _______________________________________________________________________________________________
			First				Middle				Last

               Other Names Used (alias, maiden, nickname): ___________________________________________________________

Current Address: _____________________________________________________________________________________________
	   	     Street /P. O. Box			City		State		Zip Code	County		Dates 

Former Address: _____________________________________________________________________________________________
	   	     Street /P. O. Box			City		State		Zip Code	County			Dates

Social Security Number: ___________________________ Daytime Telephone Number: _________________________

Driver’s License Number: ________________      State of Issuance: ____        Date of Birth: ___________        Gender________