Background Consent Signature | XAMK Worker


In consideration of potential selection as an independent contractor to provide requested services at an event sponsored by the General Council of the Assemblies of God or any of its ministries.

I, , hereby authorize the General Council of the Assemblies of God 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 and status now and, if applicable, during the term of my services with Chi Alpha Campus Ministries, U.S.A. of U.S. Missions of the General Council of the Assemblies of God, Inc.

I release the General Council of the Assemblies of God and/or its agents and any person or entity which 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:

Years Used Maiden Name:
 

Other Name(s):

Years Used Other Name(s):
 

Email:

Social Security Number:

Driver’s License Number:

State of Driver’s License:

Date of Birth:

Current Address:

Lived at this address:
 

Previous Address:

Lived at this address:
 

Prior Address:

Lived at this address:
 

Leave this empty:

Chi Alpha Campus Ministries https://chialpha.com
Signature Certificate
Document name: Background Consent Signature | XAMK Worker
Unique Document ID: cf7373bdf4dc0d5d52feb827c4f3f1023fe8e0d2
Timestamp Audit
April 11, 2019 12:37 pm CSTBackground Consent Signature | XAMK Worker Uploaded by Matthew Rojas - mrojas@ag.org IP 66.119.29.16, 127.0.0.1
April 11, 2019 4:51 pm CST Document owner mlynch@ag.org has handed over this document to mrojas@ag.org 2019-04-11 16:51:55 - 66.119.29.16, 127.0.0.1