New Affiliate Applicant Background Check 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:

Previous Address:

Years at this residence:

Previous Address:

Years at this residence:

Previous Address:

Years at this residence:

Leave this empty:

Chi Alpha Campus Ministries https://chialpha.com
Signature Certificate
Document name: New Affiliate Applicant Background Check Consent
Unique Document ID: 623278be0ed53524b1a0e2fc405e02832f1146e0
Timestamp Audit
November 26, 2018 1:50 pm CDTNew Affiliate Applicant Background Check Consent Uploaded by Chi Alpha Affiliations - XAAffiliations@ag.org IP 66.119.29.16, 127.0.0.1
November 26, 2018 1:53 pm CDT Document owner mlynch@ag.org has handed over this document to XAAffiliations@ag.org 2018-11-26 13:53:28 - 66.119.29.16, 127.0.0.1