HTML Preview Criminal Background Check Authorization Form page number 1.
CRIMINAL BACKGROUND CHECK
AUTHORIZATION FORM
TO BE COMPLETED BY CANDIDATE
PLEASE PRINT ALL REQUESTED INFORMATION.
Name:__________________________________________________________________________________________
Last First Middle
Other Names Used:_______________________________________________________________________________
Current Address: ________________________________________________________________________________
City/State/ZIP Code: _____________________________________________________________________________
Home Phone #: ____________________________________ Cell Phone #: _________________________________
Email Address: __________________________________________________________________________________
Social Security #:___________________________________ Date of Birth* ________________________________
The Impact Church of The Woodlands is requesting your social security number (SSN) in order to expedite this check.
Your SSN will not be disclosed to anyone except as mandated by law.
* DOB is being requested in order to obtain accurate retrieval of records
Driver’s License # ________________________________ State of Issue:____________________________________
In connection with my employment/volunteer service at The Impact Church, I hereby give authorization to conduct a
security background check on me. I understand that this security check will cover information such as criminal history,
education, employment, sanctions/exclusions, and professional licensure/certifications. I understand that this background
check may include information from previous employers relating to my work experience. I hereby release The Impact
Church and its employees, as well as the company performing the background check, from all liability resulting from the
furnishing of this information. I certify that the statements made by me on this form are true, complete, and correct to the
best of my knowledge and belief, and are made in good faith. I understand that any false statements made herein could void
my consideration for employment, or could result in disciplinary action up to, and including termination.
Signature:_________________________________________________ Date:_______________________________
With few exceptions, you are entitled (at your request) to be informed about the information The Impact Church collects
about you. Under Sections 552.021 and 552.023 of the Texas Government Code, you are entitled to receive and review the
information. Under Section 559.004 of the Texas Government Code, you are entitled to have The Impact Church correct
information about you that is held by us and is incorrect, in accordance with the procedures set forth in The University of
Texas System Business Procedures Memorandum 32. The information that The Impact Church collects will be retained
and maintained as required by Texas records retention laws (Section 441.180 et seq. of the Texas Government Code) and
rules. Different types of information are kept for different periods of time.
Area(s) you wish to volunteer/work in: ________________________________________________________________
This section to be completed by The Impact Church
Position:________________________________________ Department:__________________________________
Unit/School:_____________________________________
Request Date:____________________________________ Results Approved: □ Yes □ No HR
Representative ______________________________ Date:________________________________________