Adult Volunteer Application- Group

STRiVE CONSENT FORM FOR BACKGROUND CHECK

Applicant, please complete the following: (Complete only if your group will be working directly with individuals in service)

The following information is required by law enforcement agencies and other entities for positive identification when checking records. It is confidential and will not be used for other purposes.

Full Name (last, first, middle):

Other names used

Date of Birth:

Driver’s License #:

State of Issue:

Race:

Sex:

Male

Female

List address(es) for the past five years Include city, state, zip code, and how long you lived there. List current address first.(Required)

Address

City

State

Zip Code

Address(es) List

Address

City

State

Zip Code

Address(es) List (Click on + if more Addresses are needed)(Required)

Address

City

State

Zip Code

SIGNATURE

By signing the below, I hereby authorize STRiVE to contact me and my listed references and use the information entered on this form for the Volunteer Application process and file/information storing. I also authorize STRiVE to perform a Criminal Background Check. In connection with this request, I authorize all corporations, former employers, credit agencies, educational institutions, law enforcement agencies, city, county, state, and federal courts, military services and persons, CBI, and FBI, to release information they may have about me to the person or their agent or company with which this form has been filed. This releases the aforesaid parties from any liability and responsibility for collecting the above information. This authorization, in original form or copy form, shall be valid for this and any future reports or updates that may be requested. I authorize the procurement of my Colorado Worker’s Compensation files or any other states’ Worker’s Compensation files. I also authorize a consumer credit report to be run. I understand these files may contain negative information about my background, mode of living, character and personal reputation. This authorization, in original form or copy form, shall be valid for this and any future reports or updates that may be requested.

DATE

Volunteer Coordinator Requesting:

Ext

Name

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

Adult Volunteer Application- Group

Adult Volunteer Application Groups

Please select area(s) of interest

STRiVE CONSENT FORM FOR BACKGROUND CHECK

Applicant, please complete the following: (Complete only if your group will be working directly with individuals in service)

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