First Name

Last Name

Maiden Name

Other Names Used

Email

Phone Number

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Race

Gender

Birthdate

Have you ever been convicted of any offense other than minor traffic violations?

Yes

No

Have you ever been convicted of (or are you the subject of pending charges for) any offense involving actual or attempted child abuse or sexual molestation in any state or country?

Yes

No

If you answered “yes” to either of the previous two questions, please provide details (including dates and how it was resolved).

I hereby authorize Immanuel Bible Church and/or its agents to do the following:
Make an independent investigation of my background, references, character, past employment, education, criminal, or police 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 as a volunteer now, and if applicable, during the tenure of my volunteering or employment with Immanuel Bible Church.

Yes, I authorize

I release Immanuel Bible Church and/or its agents and any person or entity, which provides information pursuant to this authorization, from the following:
Any and all liabilities, claims, or lawsuits in regards to the information obtained from any and all of the above referenced sources used.

Yes, I agree

Background Check Consent