Criminal Background Check Template Permission Form

Criminal Background Check Permission Form

This application is to be completed by all applicants for any position (volunteer or compensated) involving the supervision, custody, or proximity of minors.  This is not an employment application form. It is intended to help SIL International provide a safe and secure environment for those children and youth who participate in our programs and use our facilities. The information in this report may affect decisions related to their employment. 

Name:                                                                                                  Date:

                  Last                                First                    Middle

Social security number:                                                                       Date of birth  

Identity must be confirmed with a driver’s license or other photographic ID.

Current Address:                                                                    Phone:                        

               City:                                                State:              Zip:                  

               Dates at this location:                                                         

Previous place of residence if current address is less than one year:

                  Street:

               City:                                                County:                                                   State:                                                 

               Zip:                          Phone:                                        Dates at this location:     

List all previous work (volunteer and employment) involving children or youth.  (List each organization’s name and address, type of work performed, and dates of service.)                         

Have you ever engaged in sexual abuse, physical abuse, a pattern of emotional abuse, or neglect of a child?  YES      NO        If yes, please explain

Have you ever been the subject of a complaint, disciplinary action, or dismissal by an employer, church, ministry, or any organization following an allegation of any actions involving a child?   YES      NO   If yes, please explain

Have you ever been the subject of investigation of any acts involving children by civil authorities? YES  NO  If yes, please explain

Have you ever viewed or been involved in child pornography  YES  NO   If yes, please explain

Department where you are serving at?

I certify that all the information I have given above is true. I understand that if I have given false or misleading information it may result in a refusal of the opportunity to serve or be hired.  I authorize SIL International. to do any kind of criminal background check on me it deems necessary.  I understand that I may request a complete and accurate disclosure of the nature and scope of the background verification, to the extent such investigation includes information bearing on my character, general reputation, personal characteristics or mode of living.  I will receive a copy of this Criminal Background Check.

Signature:                                                                                  Date:                                                                                                 

Witness:                                                                                     Date:                                                                                                 

               (if a minor, witness must be a parent)