Church Personnel and Volunteer
Criminal Background Check
Disclosure and Authorization Form
Hiring Entity Name/Address:
As a church we value the safety of children in our care, our employees and volunteers and the people whom we serve.
We want to take prudent measures to protect our human and material resources. Therefore, the Archdiocese mandates
that criminal history background checks be conducted for all Church personnel and Volunteers, who may have
unsupervised contact with a child, the elderly or persons with disabilities. Please complete this form of basic
information about you, which assures the best possible program and safety for all and return this form to the designated
Administrator for Criminal Background Checks at your Parish/School/AOD Central Services.
Contact Phone Number
*Date of Birth:
Known by any other name(s) (Maiden Name/Previous Names or Aliases Used):
Social Security #:
Number of years
If less than 7 years,