BACKGROUND CHECK FORM
NOTICE/AUTHORIZATION AND RELEASE FOR THE
PROCUREMENT OF AN INVESTIGATIVE REPORT
Applicant Information (Completely fill out the form below):
What ministry are you applying for?
Full Name:
Date:
Other Names used/ Maiden Names:
Address:
City:
State:
Mobile Phone:
Alternative Phone:
Driver’s License Number and State:
Gender:  Male  Female
Age:
Date of Birth:
I hereby authorize A Place of Change Ministry (APOC) to have the following background check
screening reports processed through the agency contacted by the church and/or its agent or
representative for employment or volunteer purposes: Application Verification, National Criminal
Report, Sexual Abuse Registry and County Court Report.
I am aware that this background check is only a screening tool and I may be asked to provide additional
information or my fingerprints to resolve issues discovered during the screening.
I understand that a photocopy or facsimile of this
signed document shall be considered as valid as an
original. I understand that I may be randomly rescreened, at any point, at the discretion of the Church.
Full Name (Please Print) Signature