Background Check and Release Form| Background Check and Release Form |
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BACKGROUND CHECK & RELEASE FORM
Name: __________________________________________
We at Christ’s Bible Fellowship, Tamuning, Guam, want to provide for the health and safety of all the individuals entrusted into our care. We are addressing the following because of our commitment to providing a safe environment for Christian growth. (Please circle each answer)
1. I have never been found guilty, or plead guilty or no contest to a criminal charge involving drugs, sexual misconduct, violence or financial misconduct. True Not True
If not true, give a short explanation of the charge. (Please indicate the date, nature and place of the incident leading to the charge, where the charge was filed and the precise disposition.)
2. No civil lawsuit alleging actual or attempted sexual discrimination harassment, exploitation or misconduct; physical abuse; child abuse; or financial misconduct has ever resulted in a judgment being entered against me, been settled out of court, or been dismissed because the statute of limitations has expired. True Not True
If not true, give a short explanation of the lawsuit. (Please indicate the date and nature of the incident leading to the lawsuit, where the lawsuit was filed and the precise disposition.)
3. I have never terminated my employment, professional credentials or service in a volunteer position, or had my employment, professional credentials or authorization to hold a volunteer position terminated, for reasons relating to allegations of actual or attempted sexual discrimination, harassment, exploitation, or misconduct; physical abuse; child abuse; or financial misconduct. True Not True
If not true, give a short explanation. (Please indicate the date of termination, name address and telephone number of employer or volunteer supervisor, and the nature of the incident(s) leading to your termination).
4. With respect to my driving record, I have not had my license suspended or revoked within the last five years due to reckless driving or driving while intoxicated and or under the influence of a controlled substance True Not True
5. Is there any fact or circumstance involving you or your background that would call into question your being entrusted with the responsibilities of the position for which you are applying or your ability to successfully accomplish the duties outlined in the position description? If yes, please provide a brief explanation. Yes No
Persons serving in the church require honesty, integrity, and truthfulness for the health of the church. To that end, I attest that the information set forth in this application is true and complete. I acknowledge that it is my duty to reasonably amend the responses and information I have provided if I come to know that the response or information was incorrect when given or, though accurate when given, the response or information is no longer accurate.
Beginning such relationships with an open exchange of relevant information builds the foundation for a continuing and healthy covenant between volunteers and the organization they seek to serve. To that end, I authorize Christ’s Bible Fellowship staff to make inquiries regarding all statements I have set forth in this application. I also authorize all entities, persons, former employees, supervisors, courts, law enforcement and other public agencies to respond to inquiries concerning me, to supply verification of the statements I have made, and to comment on and state opinions regarding my background character. To encourage such persons and entities to speak openly and responsibly, I hereby release them from all liability arising from their responses, comments, and statements made in good faith and without malice.
Signature of Applicant _____________________________________ Date __________________
Driver’s License Number and State of Issue _______________________ Expiration ______________
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