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2017-08-07T20:50:27+00:00
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CROSSROADS CHURCH
Volunteer Authorization For Release of Background Information In connection with my application for volunteer service withCHROSSROADS CHURCH, I authorize CROSSROADS CHURCH and, to, ACCUFAX Div., Southwest Inc., their agent, to solicit background information relative to my criminal record history. I understand that CROSSROADS CHURCH may conduct inquires into my background that may include criminal records, motor vehicle records, personal references, and other public record reports pertaining to me. When requested by employer, motor vehicle records or a driving history may be obtained. American Driving Records will provide motor vehicle records from the State of Louisiana. I authorize without any reservation, and person, agency, or other entity contacted by CROSSROADS CURCH or ACCUFAX Div., Southwest Inc., their agent, and employees and all personas, agencies, and entities providing information arising out of furnishing any such information or reports. I agree that my electronic signature is the legally binding equivalent to my handwritten signature.
Name
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First
Last
Date of Birth
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Other Names Used
Social Security Number
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Drivers LIC #
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State Issued
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Address
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Address Line 1
Address Line 2
City
--- Select state ---
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Alaska
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California
Colorado
Connecticut
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District of Columbia
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Louisiana
Maine
Maryland
Massachusetts
Michigan
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Mississippi
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Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
How Long at this Address?
*
(months/Years)
Previous Address
Address Line 1
Address Line 2
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
How Long at this Address?
*
(months/Years)
List ALL City/ States Resided in Since Age 18 and How Long in Each Location.
Date / Time
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Date
Time
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