Adobe FormsCentral

Background Check:
Have you ever abused or molested a youth? *

Yes No
Were you ever abused or molested as a youth? *

Yes No
If yes, please explain:
Have you ever been convicted of a felony or misdemeanor? *

Yes No
If yes, when and for what?
Have you ever undergone treatment for alcohol or substance abuse? *

Yes No
If yes, please explain:
List names and daytime phone numbers of three references.
Name *
Telephone *
Name *
Telephone *
Name *
Telephone *
I certify that all the information submitted by me on the application is true and complete to the best of my knowledge, and I understand that any false information, omissions, or misrepresentation of facts called for on this application may be cause for denial of my application or, if I am already a 360 Blueprint volunteer, discharge at any time. By my signature and of my free will, I do hereby agree to indemnify and not hold culpable 360 Blueprint and its agents for any and all claims or demands, costs or expenses arising out of any injuries, damages or other losses, whether personal or property sustained by me during any 360 Blueprint activity. By signing this document, I agree to have the above references contacted. Please note that the above information will be held in your personal file and on the jobsite in case of an emergency.
Signature - please print *
Date *

/ Month / Day Year
Date

Volunteer Consent to Background Check
Name: *
Date of Birth *

/ Month / Day Year
Date
Address: *
Phone number *
State: *
City: *
Zip code: *
E-mail:
Are you 18 years of age or older? *

Yes No
Driver License Number *
State: *
Have you ever been convicted of, or pled guilty or no contest to a crime other than a minor traffic violation, or are you now under charges of any criminal offense? A crime conviction will not necessarily disqualify you from consideration. *

Yes If yes, please describe each conviction. No
State:
County:
Date of offense:

/ Month / Day Year
Date
Details of Conviction:
Have you ever received deferred adjudication or similar disposition for any federal, state or municipal offense? *

Yes If yes, please provide details below. No
State:
County:
Date of offense:

/ Month / Day Year
Date
Details of Conviction:
In consideration of the receipt and evaluation of this application by 360 Blueprint, I agree and represent that: The information contained in this application is correct to the best of my knowledge. I authorize references or any other person or organization, whether identified or not identified in this packet to give you any information (including opinions) regarding my character and fitness for the job description. i hereby release any individual, 360 Blueprint staff or church official, reference, or any other person or organization, whether or not identified in this packet, of any and all liability for damages of whatever kind or nature which may result through the process of the background investigation. I FURTHER STATE THAT I HAVE CAREFULLY READ THE FOREGOING RELEASE AND KNOW THE CONTENTS THEREOFA ND SIGN THIS RELEASE AS MY OWN FREE ACT. This is a legally binding release, which I have read and understand. I understand that I may consult with an attorney before signing this document. A facsimile or photocopy of this authorization shall be as valid as the original. I further understand that a criminal record check may be conducted on me and I consent to any such check, as long as I remain a volunteer or staffed with 360. The above-mentioned may be repeated at any time.
Signature *
Date *

/ Month / Day Year
Date