Background Information Release Form

Please read the form carefully and fill in the requested information. If we have any other questions after submission, we’ll be in touch.

"*" indicates required fields

Company

This field is for validation purposes and should be left unchanged.

Name*

First Last

Home Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Email*

Phone*

Phone Type

Mobile

Home Landline

Date of Birth*

Social Security Number*

Driver's License State

Only required for those needing a Motor Vehicle Report

Driver's License #

Only required for those needing a Motor Vehicle Report

Job Title / Position*

Home Church (Name and City)*

Contact at Home Church*

First Last

Contact at Home Church Email*

Background Checks Needed*

Criminal and Social Security Trace (Verified Plus) - $11.50

Credit Check - $6.75

Motor Vehicle Report - $10.15

Nominees for Ordination (Check NO Other Boxes) - $439.50

Criminal and Social Security Trace (Verified Plus)

Price:

Credit Check

Price:

Motor Vehicle Report

Price:

Nominees for Ordination

Price:

Total

Choose How to Pay*

Pay by Mail (The Diocese of West Missouri | 420 W. 14th St., Kansas City, MO 64105)

Pay Electronically

Payment Method*

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

I hereby authorize The Diocese of West Missouri, 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 any time while I am under the care of the Diocese of West Missouri. The purpose of this consent is to authorize the Diocese of West Missouri to confirm the information on my application for employment and/or obtain any other information relating to my qualifications for employment or volunteer service with the Diocese of West Missouri, now or at any time during the tenure of such employment or volunteer service. I release The Diocese of West Missouri and/or its agents and any person or entity, which provides information to this authorization, from any and all liabilities, claims or lawsuits in regard to the information obtained from any and all of the above referenced sources used. All information contained herein is true and correct to the best of my knowledge.

Signature*

Date*

CAPTCHA

Background Information Release Form

Previous PostClergy/Nominee Information Form

Next PostSafe Church Policy

About

News & Events

Resources & Administration

Annual Convention