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United Methodist Church 501 Hampton Lane (Beltway Exit 27B & Dulaney Valley Road) email: towsonumc@towsonumc.org Towson, Maryland 21286 410-823-6511 Elevator is available to access all 3 floors! .
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APPENDIX D
POLICY OF THE TOWSON UNITED METHODIST CHURCH FOR THE PREVENTION OF ABUSE OF CHILDREN AND YOUTH
CONSENT TO PERFORM CRIMINAL HISTORY/BACKGROUND CHECKIN COMPLIANCE WITH THE FCRA (FAIR CREDIT REPORTING ACT) THE TOWSON UNITED METHODIST CHURCH
________________________________________ Last Name First Name Middle Name or Initial
____________________________________ Maiden or other name(s) used in any and all other records of birth or records of residence
__________________________________________ Address Apartment or
__________________________________________ City County State Zip
___________________________________________ **Date of Birth Place of Birth Social Security Number **Gender Race
____________________________________ Drivers License Number State Phone (H) Phone (W)
_____________________________________________ E-mail Photo ID? Y/N
__ _____________________________________________ Emergency Contact Phone
**TO BE USED FOR CRIMINAL HISTORY CHECKS ONLY AND NOT A PART OF THE PERSONNEL FILE
References – Name Phone Number
1. ___________________________
2. _______________________________________
3. _________________________________________
I, , am an applicant for employment / volunteer work with The Towson United Methodist Church (“TUMC”) and have been advised that as a part of the application process, TUMC conducts a Criminal History background check. I do hereby consent to the use by TUMC of any information provided during the application process in performing the Criminal History check. TUMC has informed me that I have the right to review and challenge any negative information that would adversely impact a decision to offer employment/volunteer work. In addition, I have been informed that I will have a reasonable opportunity to clear up any mistaken information reported within a reasonable time frame established within the sole discretion of TUMC. Under the Fair Credit Reporting Act, I have been advised that, upon request, I will be provided the name, address, and telephone number of the reporting agency as well as the nature, substance, and source of all information.
The following are my responses to questions about my Criminal History (if any).
1. YES NO Have you ever been convicted of, or plead guilty before a court for, any federal, state, or municipal criminal offense? (Exclude minor traffic misdemeanors.) If yes, please provide details below.
State: County: Date of Offense: / /____________ Details of conviction:
2. YES NO Have you ever received deferred adjudication or similar disposition for any federal, state, or municipal offense? If yes, please provide details below.
State: County: Date of Offense: / /____________ Details of offense:
3. YES NO Have you ever received probation or community supervision for any federal, state, or municipal offense? If yes, please provide details below.
State: County: Date of Offense: / /____________ Details of supervision:
4. YES NO Have you ever been convicted of any criminal offense in a country outside the jurisdiction of the United States? If yes, please provide details below.
Country: City: Date of Offense: / /____________ Details of conviction:
5. YES NO As of the date of this consent form, do you have any pending charges against you? If yes, please provide details below.
State: County: Date of Arrest: / /____________ Details of pending charges:
THIS SECTION IS TO BE USED TO LIST ALL COUNTIES AND STATES OF RESIDENCE SINCE HIGH SCHOOL GRADUATION OR AGE 18.
CITY/TOWN COUNTY STATE COUNTRY
______________________________ _____________________________________ ___________________________________ _______________________________ __________________________________________ ______________________________ _____________________________________ _______________________________________________ ___________________________________________________ __________________________________________________ _____________________________________________
I HEREBY CERTIFY THAT ALL INFORMATION PROVIDED IN
THIS CONSENT FORM IS TRUE, CORRECT,
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