Background Check

<Please print (by right clicking)  complete and turn into Chairman of Deacons>
STATEMENT OF UNDERSTANDING
 And CRIMINAL BACKGROUND CHECK REQUEST

1.  Legal Name: _____________________________________
2. Maiden Name (If Applicable):__________________________
3. Date of Birth: __________________________________
4. Social Security Number: _____________________________
5. Gender :      (circle one)      Male               or               Female
6. Race: ______________________________

STATEMENT OF UNDERSTANDING
 I acknowledge that I have been advised that a Criminal Background Check will be conducted and that employment or volunteer assignments are contingent upon the results of this check.  The nature of the offense as it relates to the position will depend upon whether I am offered employment or a volunteer position.
Signature of Church Member
                                                   ________________________________DATE:_____________

 Date Requested: _____________
Requested By: _________________________________

                    To be completed by the Chairman of Deacons

_______ APPROVED FOR HIRE
_____DISAPPROVED FOR HIRE

Results Reported BY:_________________________
DATE:_______________