St. John's United Methodist Church

Lutherville, Md

BACKGROUND CHECK

AUTHORIZATION FORM

I,___________________________________ , hereby authorize St. John's United Methodist Church to request information regarding any record of changes or convictions contained in any criminal file on me, whether said crimes are committed against minors, to the fullest extent permitted by state and federal law.

Signature of Applicant __________________________________Date: ______________________

Print applicant's full name: ________________________________
Print all other names that have been used by applicant (if any):

Date of Birth:___ /____ /________

Place of Birth: __________________

Social Security Number: _____-_______-_________

Driver's License Number: ________________________________ State: _______

All personal information will be held by St. John's United Methodist Church and will not be released without written permission.