Chi Alpha Campus Ministries

CMIT Applicant Spouse- 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 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 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:


Maiden Name:

Nickname/Preferred Name:


Social Security Number:

Date of Birth:

Current Address:

Previous Address:

Please list below all residences where you have lived in the past five years.

Leave this empty:

Chi Alpha Campus Ministries
Signature Certificate
Document name: CMIT Applicant Spouse- Background Consent
Unique Document ID: f930c6ffcbbd56f484bf1e9d2bfa949897d800e5
Timestamp Audit
October 20, 2017 1:38 pm CSTCMIT Applicant Spouse- Background Consent Uploaded by Melanie Lynch - IP