VOLUNTEER
Catholic Diocese of
Background Information Consent
I, ______________________________________,
hereby authorize the Catholic Diocese of Dodge City and/or its agents,
affiliates, parishes and representatives, to make an independent investigation
of my background, references, past employment, education, criminal or police
records, child or adult abuse and neglect registries, including those
maintained by both public and private organizations and all public records for
the purpose of confirming the information contained on my Application and/or
obtaining other information which may be material to my qualifications for
employment now, and if applicable, during the tenure of my employment with the
Catholic Diocese of Dodge City, its parishes or affiliates.
I release the Catholic Diocese of Dodge City
and/or its agents, affiliates, parishes and representatives as well as any
person or entity which provides information pursuant to this authorization,
from any and all liabilities, claims, or law suits arising out of or in any
manner related to information obtained from any and all of the above referenced
sources used.
The following is my true and complete legal
name and all information contained herein is true to the best of my knowledge:
Full Name (Printed):
_________________________________________________________________
Maiden Name or Other Names Used:
____________________________________________________
Present Address:_______________________________________________
How long?_____________
City/State:
__________________________________________________ Zip: ____________________
Former Address:
_____________________________________________ How long?_______________
City/State:
__________________________________________________ Zip: ____________________
*Date of Birth: _______________________
*Social Security Number: __________________________
Applicant/Employee Signature:
____________________________________ Date: ___________________
*NOTE: This information is required for
identification purposes only, and is in no manner used as a qualification for
employment.
Revised: 08/16/07