Background Check Form

Background Check Authorization Form

* Indicates required field

Name (First) (Middle) and (Last): *

Former Name(s) and Dates Used: *

Current Address Since: (Mo/Yr) (Street) (City) (Zip/State) *

Previous Address or Addresses For last five years: (Mo/Yr) (Street) (City) (Zip/State) *

Social Security Number: *

Date of Birth: *

Phone Number *

Driver's License Number / State: *

The information contained in this application is correct to the best of my knowledge. I hereby authorize BEACON OF HOPE CRISIS CENTER and its designated agents and representatives to conduct a comprehensive review of my background causing a consumer report and/or an investigative consumer report to be generated for employment and/or volunteer purposes. I understand that the scope of the consumer report/ investigative consumer report may include, but is not limited to the following areas: verification of social security number; current and previous residences; employment history, education background, character references; drug testing, civil and criminal history records from any criminal justice agency in any or all federal, state, county jurisdictions; driving records, birth records, and any other public records.

I further authorize any individual, company, firm, corporation, or public agency (including the Social Security Administration and law enforcement agencies) to divulge any and all information, verbal or written, pertaining to me, to BEACON OF HOPE CRISIS CENTER or its agents. I further authorize the complete release of any records or data pertaining to me which the individual, company, firm, corporation, or public agency may have, to include information or data received from other sources.

I hereby release BEACON OF HOPE CRISIS CENTER, the Social Security Administration, and its agents, officials, representative, or assigned agencies, including officers, employees, or related personnel both individually and collectively, from any and all liability for damages of whatever kind, which may, at any time, result to me, my heirs, family, or associates because of compliance with this authorization and request to release.

I attest my authorization and agreement to all of the above: *

Applicant's Signature

Applicant Printed Name: *

Date of my authorization, agreement and submission of this completed background check form: *

Submit

Background Check Authorization Form

Main Office Line:(317)731-6131Crisis Call line:(317)731-6140

Main Office Line:
(317)731-6131

Crisis Call line:
(317)731-6140