Background Screening Consent

Personal Information

Name

Full Name

Maiden Name or Other Names Used

Date of Birth

Social Security (Format: xxx-xx-xxxx)

This address will receive a confirmation email

Driver's License Number:

Residential Information

Address

How long have you lived at your current address?

What was your previous address?

How long were you at this address?

Please list all states and counties of residence since turning age 18:

Please check any of the following states in which you have lived: CA CO DE LA MA SD VT WV WY

Statements of Consent

I hereby authorize Grace Point Church and/or its agents to make an independent investigation of my background that may include: adult criminal or police records, and motor vehicle records including those maintained by both public and private organizations and all public records for the purpose of confirming the information contained on my application and/or obtaining other information which may be material to my qualifications for service now and, if applicable, during the tenure of my service with Grace Point Church.

I Agree.

I release Grace Point Church and its agents and any person or entity, which provides information pursuant to this authorization, from any and all liabilities, claims or law suits in regards to the information obtained from any and all of the above referenced sources used. The information provided is my true and complete legal name and all information is true and correct to the best of my knowledge.

I agree.

Payment Information

The $25 fee is the exact cost of running the background check. The church does not receive any of this money. This is not considered a "donation" to the church.

Background Check Fee $25.00

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Background Screening Consent

Description

Please Fix the Following