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Local Police Check

Catholic Charities requires a police check for all volunteer mentors according to agency policy. The document provides a consent form for an individual to sign, allowing local, county, state police, and law enforcement agencies to release any information about the individual to Catholic Charities. It requests identifying information such as name, address, date of birth, driver's license number, and previous addresses to conduct the background check.

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87 views2 pages

Local Police Check

Catholic Charities requires a police check for all volunteer mentors according to agency policy. The document provides a consent form for an individual to sign, allowing local, county, state police, and law enforcement agencies to release any information about the individual to Catholic Charities. It requests identifying information such as name, address, date of birth, driver's license number, and previous addresses to conduct the background check.

Uploaded by

mpriceatccusa
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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LOCAL POLICE CHECK

In accordance with agency policy, Catholic Charities is authorized to conduct a police


check on volunteer mentors.
Name:

__________________________________________________

Address:

__________________________________________________
__________________________________________________

As an adult member of this household, I hereby give my permission for local, county,
state police and law enforcement agencies to release to Catholic Charities any and all
information relating to me.
_________________________________________
______________________
Signature

Date

(Please complete all of the following information in full.)


Full Name: _________________________________________ Sex: _______
Birth Date:
___________________ Race: ____________________________
Place of Birth: _____________________________________________________
Social Security Number:
_________________________________________
Drivers License Number:
_________________________________________
Maiden Name (if Applicable):
___________________________________
Former Married Names:
___________________________________
Any Other Names Used:
___________________________________
Previous Addresses (if current address is less then 5 years):
Street:________________________ Town: ___________________ State: _____
FOR POLICE USE BELOW:
No Record ____________ Record Attached _____________
Other Comments (use back of page if necessary) :
_______________________________________________________________________
_______________________________________________________________________
__

_________________________
______________________________
____________
Name
Signature
Date
Position: ________________________ Police Dept./Agency: _____________________

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