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Name*
First Middle Last
Maiden Name (if applicable)
Last
Email*
How many places have you lived over the past five years?*
Current Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Previous Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Previous Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Previous Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Previous Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
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Background Consent

I, , hereby authorize Assemblies of God U.S. Missions and/or its agents to make an independent investigation of my background, references, character, past employment, education, credit history, criminal or police records, including those maintained by both public and private organization and all public records for the purpose of confirming the information contained on my application and/or obtaining other information that may be material to my qualifications for U.S. Missions status now, and if applicable, during the tenure of my ministry with Assemblies of God U.S. Missions.

I release Assemblies of God U.S. Missions and/or its agents and any person or entity that provides information pursuant to this authorization from any and all liabilities, claims, or lawsuits in regards to the information obtained from any and all of the above referenced sources used.

The following is my true and complete legal name and all information is true and correct to the best of my knowledge:

Name:

Maiden Name:

Email:

Social Security Number:

Date of Birth:

Current Address:

Years at this residence:

Previous Address:

Years at this residence:

Leave this empty:

Your legal name

Your email address

Timestamp

Audit

July 6, 2017 2:51 pm CDT

Background Consent Uploaded by Chi Alpha Affiliations - [email protected] IP 66.119.29.16

July 7, 2017 8:43 am CDT

Document owner [email protected] has handed over this document to [email protected] 2017-07-07 08:43:37 - 66.119.29.16