Personal Information:
* First Name
* Last Name
MI
List Other Names used (maiden, former,nickname,a/k/a's)
* Home Phone
Cell Phone
* Email
Position for which this application is being made
Marital Status Married Single Engaged Divorced Remarried Widowed
Social Security Number
Driver's License State (select a state) New York New Jersey Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Other
Driver's License Number
First Institution
School Name
Address Line 1
Address Line 2
Country (select a country) United States Canada Afghanistan Albania Algeria Andorra Angola Antigua & Deps Argentina Armenia Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bhutan Bolivia Bosnia Herzegovina Botswana Brazil Brunei Bulgaria Burkina Burundi Cambodia Cameroon Canada Cape Verdi Central African Rep Chad Chile China Columbia Comoros Congo Congo {Democratic Rep} Costa Rica Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland France Gabon Gambia Georgia Germany Ghana Greece Greneda Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hungary Iceland India Indonesia Iran Iraq Ireland {Republic} Israel Italy Ivory Coast Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea North Korea South Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Morocco Mozambique Myanmar {Burma} Namibia Narau Nepal Netherlands New Zealand Nicaragua Niger Nigeria Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Qatar Romania Russian Federation Rwanda St Kitts & Nevis St Lucia St Vincent & Grenadines San Marino Sao Tome & Principe Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikstan Tanzania Thailand Togo Tonga Trinidad & Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Western Samoa Yemen Yugoslavia Zambia Zimbabwe
City
State/Province (select a state) New York New Jersey Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Other
ZIP/Postal Code
Second School
Institution Name
first Home Address
Second Home Address
Name and address of the church of which you are a member
Name and address of churches you have attended regularly during the past five years
List All Previous Church Work Involving youth(name,address,dates,type of work)
List any gifts, callings, trainings,education, or other factors that have prepared you for work with children/and or youth
List your employers for the past 10 years
Have you had any driver's lisence or other license(e.g., professional) suspended or revoked? if so, give full details.
Have you ever been arrested or charged with driving under influence? if so, list each such arrest or charge, when and where it was made and its outcome.
Have you ever been convicted of child abuse or crime involving actual or attempted sexual molestation of a minor? If so please explain
Has any formal or informal charge, compalin, or complaint ever been made that you engaged in inappropriate sexual behavior? If so, give full details.
Is there any fact or circumstances about you or your background that would call into question the advisability of entrusting you with the supervision, guidance, and care of yound people?
First Reference
* Name
Street
City, State & Zip
Telephone
Second Reference
Name
Under Penalty of Prejury, I swear or affirm that the information given above is true, complete, and correct. I understand and agree that a complete background investigationmay be conducted with respect to me, and that this information may be verified by contacting persons, and organizations with whom i have had contact or which may have information concerning me. I hereby release and agree to hold harmless from liability any person or organization that provides such information. I also agree to release and hold harmless the church and (name of congregation), their officers, employees, agents, and volunteers from any and all liability as it relates to any inverstigation taken by them regarding the information contained in this application, or any action by them as result of such investigation.
I Agree I agree to the terms *
* Applicant's Name
Parent/Guardian's Name(If applicant is under 18 years old)
Parent/Guardian's Name