Screening Form

Team Member Application and Permission to Obtain a background screening

(This form authorizes Osceola Grace Brethren Church to obtain background information and must be completed by the applicant. Completed forms will be retained by the church for a minimum of five (5) years after a background check has been requested.)
In the interest of safety and security I, the undersigned applicant (also known as the “consumer”), authorize Osceola Grace Brethren Church through its independent contractor to procure background information (also known as a “consumer report and/or investigative consumer report”) about me, prior to, and at any time during, my service to the organization. This report may include my driving history, including any traffic citations; a social security number verification; present and former addresses; criminal and civil history/records; and the state sex offender records.
I understand that I am entitled to a complete copy of any background information report of which I am the subject upon my request to Osceola Grace Brethren Church, if such is made within a reasonable time from the date it was produced. I also understand that I may receive a written summary of my rights under the Fair Credit Reporting Act.

* Indicates required field

Applicant *

First

Last

Parent/ Guardian in the event the above is a minor *

First

Last

By checking the box below, I authorize Osceola Grace to perform the above checks. *

Yes - I authorize the checks as noted above.

Email *

Phone Number: *

Daytime Phone Number *

Parent/Guardian relation to applicant: *

Other names used by applicant (alias, maiden, nicknames or "none"): *

Team Member's Address Information *

Line 1

Line 2

City

State

Zip Code

Country

Mother's Maiden Name *

Social Security # (confidential) *

Driver's License # *

State Issued *

Gender *

Male Female

Birth Date *

Confirm