AUTHORIZATION

    In connection with your application for employment or volunteer service with: Calvary Chapel Port Saint Lucie West, Inc., d/b/a Calvary Port St Lucie (including any independent contract for services) or when deciding whether to modify or continue your ongoing employment (if employed) or volunteer service, Calvary Port St Lucie may obtain a “consumer report” and/or an “investigative consumer report” on you from SecureSearch, a consumer reporting agency, or from any third party, in strict compliance with both state and federal law. A consumer report is a communication of information by a consumer reporting agency bearing on your credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living which is used or expected to be used for purposes of serving as a factor in establishing your current and/or continuing eligibility for employment purposes. An investigative consumer report is a report obtained through personal interviews with individuals who may have knowledge of your character, general reputation, personal characteristics, or mode of living. The consumer reports or investigative consumer reports may contain information regarding your credit history (if applicable to position), criminal records, driving history records, education records, previous employment history, social security traces, military records, professional licensure records, drug testing, government records, and other types of background information. You further understand that these reports may contain information concerning the reasons for termination of past employment. You are hereby notified that you have the right to make a timely request for the nature and scope of any investigative consumer report. You are further notified that, prior to being denied employment based in whole or in part on information obtained in the consumer report, you will be provided a copy of the report, the name, address and telephone number of the consumer reporting agency and a description in writing of your rights under the Fair Credit Reporting Act. Inquiries to SecureSearch should be directed to SecureSearch; Consumer Disputes; 558 Castle Pines Pkwy. #B4-137, Castle Rock, CO 80108. 1 (866) 891 – 1954.

    THE FOLLOWING IS INFORMATION REQUIRED IN ORDER FOR CALVARY PORT ST. LUCIE TO OBTAIN A COMPLETE CONSUMER REPORT:

    FULL LEGAL NAME ( First, Full Middle Name, Last Name)(required)

    SOCIAL SECURITY NUMBER (required)

    DATE OF BIRTH (required)

    STREET ADDRESS

    CITY, STATE , ZIP CODE

    DRIVER'S LICENSE NUMBER AND ISSUE DATE

    OTHER OR FORMER NAMES (AKA, Maiden Names, Married Names, Surnames, Etc. )

    BY ENTERING YOUR NAME BELOW YOU ARE ELECTRONICALLY SIGNING THAT THE INFORMATION PROVIDED IS CORRECT.

    APPLICANT'S SIGNATURE DATE

    THIS INFORMATION WILL BE USED FOR BACKGROUND SCREENING PURPOSES ONLY

    PLEASE LIST ALL COUNTIES AND STATES YOU HAVE LIVED IN SINCE THE AGE OF 18 . PLEASE PROVIDE THE FOLLOWING INFORMATION . COUNTY, STATE , NAME USED IN COUNTY, DATE FROM AND DATE TO

    DISCLOSURE

    In connection with your application for employment or volunteer service with: Calvary Port St Lucie (including any independent contract for services) or when deciding whether to modify or continue your ongoing employment (if employed) or volunteer service, Calvary Chapel Port St Lucie may obtain a “consumer report” and/or an “investigative consumer report” on you from SecureSearch, a consumer reporting agency, or from any third party, in strict compliance with both state and federal law. A consumer report is a communication of information by a consumer reporting agency bearing on your credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living which is used or expected to be used for purposes of serving as a factor in establishing your current and/or continuing eligibility for employment purposes. An investigative consumer report is a report obtained through personal interviews with individuals who may have knowledge of your character, general reputation, personal characteristics, or mode of living. The consumer reports or investigative consumer reports may contain information regarding your credit history (if applicable to position), criminal records, driving history records, education records, previous employment history, social security traces, military records, professional licensure records, drug testing, government records, and other types of background information. You further understand that these reports may contain information concerning the reasons for termination of past employment. You are hereby notified that you have the right to make a timely request for the nature and scope of any investigative consumer report. You are further notified that, prior to being denied employment based in whole or in part on information obtained in the consumer report, you will be provided a copy of the report, the name, address and telephone number of the consumer reporting agency and a description in writing of your rights under the Fair Credit Reporting Act. Inquiries to SecureSearch should be directed to SecureSearch; Consumer Disputes; 558 Castle Pines Pkwy. #B4-137, Castle Rock, CO 80108. 1 (866) 891 – 1954.

    THE FOLLOWING ARE MY RESPONSES TO QUESTIONS ABOUT MY CRIMINAL RECORD HISTORY (IF ANY) WITH DESCRIPTIONS TO ANY QUESTION WITH A YES ANSWER:

    NAME:

    1. HAVE YOU EVER BEEN CONVICTED OR PLEAD GUILTY BEFORE A COURT OF ANY FEDERAL STATE, OR MUNICIPAL CRIMINAL OFFENSE? (EXCLUDING MINOR TRAFFIC VIOLATIONS)
    YesNo

    IF YES, PLEASE EXPLAIN:

    2. HAVE YOU EVER RECEIVED DEFERRED ADJUDICATION OR SIMILAR DISPOSITION FOR ANY FEDERAL, STATE OR MUNICIPAL CRIMINAL OFFENSE?

    YesNo

    IF YES, PLEASE EXPLAIN:

    3. HAVE YOU EVER RECEIVED PROBATION OR COMMUNITY SUPERVISION FOR ANY FEDERAL, STATE OR MUNICIPAL CRIMINAL OFFENSE?

    YesNo

    IF YES, PLEASE EXPLAIN:

    4. HAVE YOU EVER BEEN CONVICTED OF ANY CRIMINAL OFFENSE IN A COUNTRY OUTSIDE THE JURISDICTION OF THE UNITED STATES?

    YesNo

    IF YES, PLEASE EXPLAIN:

    5. AS OF THE DATE OF THIS AUTHORIZATION, DO YOU HAVE ANY PENDING CRIMINAL CHARGES AGAINST YOU?

    YesNo

    IF YES, PLEASE EXPLAIN:

    6. HAVE YOU EVER SERVED IN THE US MILITARY?

    YesNo

    7. IF YOU ANSWERED YES TO THE ABOVE QUESTION, DID YOU RECEIVE A DD214?

    IF YES , CAN YOU PRESENT THE DOCUMENT?

    8. IF YOU ANSWERED YES TO THE ABOVE QUESTION 6, DID YOU RECEIVE AN HONORABLE DISCHARGE?

    IF NO, PLEASE EXPLAIN:

    BY ENTERING YOUR NAME BELOW YOU ARE ELECTRONICALLY SIGNING THAT THE INFORMATION PROVIDED IS CORRECT.

    APPLICANT'S SIGNATURE & DATE

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