Consent for Background Check "*" indicates required fields Your signature below authorizes South Spring Baptist Church Tyler, TX and One Source The Background Check Company to obtain information about you from various law enforcement agencies, courts, and corrections agencies. SSBC has requested not to receive any consumer and/or credit information, only information that pertains to criminal background. Full Legal Name* First Last Email* Phone*Gender* Male Female Current Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Other Names Used (Maiden, alias’, legal name change, etc.)Date of Birth* MM slash DD slash YYYY Social Security Number* Driver's License Number State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificPrevious addresses in the past 7 years:Have you ever been convicted of a crime?* Yes No Please explain:Applicant’s signature: I have reviewed and completed this form as applicable to me. I give South Spring Baptist Church Tyler, TX permission to verify any information I have provided. This authorization shall continue to be effective until revoked by me. A photocopy or facsimile copy of this consent shall be as effective as the original. By my signature, I affirm that all information on this form is true and accurate. Signature:* Date* MM slash DD slash YYYY Summary of Rights Under the Fair Credit Reporting ActCommentsThis field is for validation purposes and should be left unchanged. Δ
