Authorization for Background Check

Infant / Child / Youth Worker

I hereby authorize Sugar Land Bible Church and its authorized representatives to obtain any information pertaining to my juvenile or adult criminal record, social security and driving history, and any other relevant information deemed necessary.

I hereby release Sugar Land Bible Church and its authorized representatives, and any governmental or private agency or other repository of criminal records, social security or driving records, from any and all liability for damage of whatever kind, because of compliance with this authorization.

Signature*

Date*

Name*

First Last

Date of Birth*

Driver's License Number*

Driver's License State*

State

Social Security Number*

Maiden/Alias/Other Name(s) (If different from full name above)*

First Last

NOTE: For women, your maiden name is your full name that you were given at birth. Also, please list any married name or names that you have used since birth. For example, you were given the name Sally Jean Smith at birth. You were just married to John Brown, and your current full name is Sally Smith Brown. You would list Sally Jean Smith as your maiden name.

Place of Birth*

City State / Province / Region Country

Current Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

How long have you lived at this address?*

Previous Addresses

If at current address for less than 7 years.

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

How Long at this address?

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

How Long at this address?

Children's Ministry Background Check