Background Check Forms Revision 2:1, 12/31/2008
Consumer, Investigative, and Direct Reports Authorization, Disclosure and Release

Name

Social Security no.

Date of birth (mm/dd/yyyy)*

Street address

City

State

Zip Code

Driver’s license no.

State of issuance

Any other names used

By signing below, I hereby voluntarily authorize International Church of the Foursquare Gospel d/b/a______________________________________________________________________ (legal name and code number of church, school, camp ) (“Foursquare”) to obtain “consumer reports” and “investigative consumer reports” about me from a “consumer reporting agency,” and reports Foursquare may obtain directly, and to consider these reports when making decisions regarding my employment/volunteer position or potential position with Foursquare. The nature and scope of these reports are as follows. They may contain information on my character, general reputation, personal characteristics, and mode of living. They may also include, among other things, checks, records and/or information regarding: my criminal convictions (including, without limit, court, sex offender, incarceration and DMV records), social security number, current and prior employer(s)/supervisor(s) and/or references I provided, coworkers, neighbors, friends, associates or acquaintances, and verification of college degrees and professional licenses or certifications.

I understand that I have rights under the Fair Credit Reporting Act (and the California Investigative Consumer Reporting Agencies Act and other California law for California residents, the Government Data Practices for Minnesota residents, the Credit Services Organization Act for Oklahoma residents, the equivalent New York FCRA for New York residents, and the equivalent Maine FCRA for Maine residents) including the rights discussed in the separate disclosure statement(s) provided to me.

I authorize any governmental entity, law enforcement agency, institution, information service bureau, school, employer, supervisor, reference, or other person contacted by Church Volunteer Central (or other selected agency) or Foursquare, or their agents or volunteers, to furnish the information described herein.

I release and discharge from liability all persons, agencies, and entities providing the above information or reports about me to Church Volunteer Central (or other selected agency) and/or Foursquare. To the fullest extent permitted by law, I further release and discharge Foursquare and Church Volunteer Central (or other selected agency), and their agents, employees and volunteers, from any claims, damages, losses, liabilities, costs and/or expense arising from the retrieving and/or reporting of said information, including any consumer report or investigative consumer report.

I acknowledge a copy or telephonic facsimile of this document shall be valid as the original. If I am presently a resident of Maine or New York, I have reviewed the additional state law disclosure information attached.

Signature

Date


If you would like a copy of any investigative consumer report sent to you at your address listed above, please check the box below.

□ Yes, I would like to receive a copy of any investigative consumer report which may be obtained on me by a consumer reporting agency.
□ If you would like to receive a copy via email, please provide your email address.

_______________________________________________________________________________________
Your date of birth is requested to verify the information obtained is about you and not someone with the same or a similar name. It will not be used for employment purposes.