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Background Check Authorization Form
Fill out the form below with your information.
Questions? Call the office at (541) 899-1287
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Former Name(s) and Dates Used
Current Address Since
Social Security Number
Date of Birth
Driver's License # and State
The information contained in this application is correct to the best of my knowledge. I hereby authorize
Jacksonville Presbyterian Church (JPC)
and its designated agents and representatives to conduct a comprehensive review of my background causing a consumer report and/or an investigative consumer report to be generated for employment and/or volunteer purposes.
I understand that the scope of the consumer report/investigative consumer report may include, but is not limited to the following areas: verification of social security number; credit reports, current and previous residences; employment history, education background, character references; drug testing, civil and criminal history records from any criminal justice agency in any or all federal, state, county jurisdictions; driving records, birth records, and any other public records.
I further authorize any individual, company, firm, corporation, or public agency (including the Social Security Administration and law enforcement agencies) to divulge any and all information, verbal or written, pertaining tome, to
or its agents. I further authorize the complete release of any records or data pertaining to me which the individual, company, firm, corporation, or public agency may have, to include information or data received from other sources.
and its designated agents and representatives shall maintain all information received from this authorization in a confidential manner in order to protect the applicants personal information, including, but not limited to, addresses, social security numbers, and dates of birth.
By typing your name above, you consent to electronic signature.
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PO Box 297
425 Middle Street
Jacksonville, Oregon 97530