HTML Preview Chruch Background Check Authorization Form page number 1.
Binkley Baptist Church Permission to Obtain a Background Check
This form authorizes Binkley Baptist Church to obtain background information and must be completed by all
volunteers who work with children and youth (see the Safe Church Handbook) and all Binkley employees. The
church must keep this completed form on file for at least two years after requesting a background check.
I, the undersigned volunteer / employee, authorize Binkley Baptist Church through its independent contractor,
LexisNexis, to procure background information about me. This report includes my social security number
verification; present and former addresses; criminal and civil history/records; and the state and national sex
offender records.
I understand that I am entitled to a complete copy of any background information report of which I am the
subject upon my request to Binkley Baptist Church, if such is made within a reasonable time from the date it was
produced.
Signature: ___________________________________________________________Date: _________________
Print Name: _______________________________________________________________________________
First Middle Last
Other names used (alias, maiden, nickname): ____________________________________________________
Current Address: ___________________________________________________________________________
Street/PO Box City State Zip County Dates
Former Address: ___________________________________________________________________________
Street/PO Box City State Zip County Dates
Social Security Number: __________________________ Daytime Phone Number: ______________________
Driver’s License Number: __________________ State Issued: _______ Date of Birth: _______ Gender: _____
_____ I will be driving for church activities.
This background check only checks for criminal histories, verifies social security number and address. It does not
check your credit history or other personal information. This form and the results of the background check are
always kept confidential.