| Back
Print form DIOCESE
OF ALLENTOWN
Lay Employee / Volunteer Background Check Authorization
THIS
FORM MAY BE REPRODUCED
Full
Name (Print)
_________________ ____________________ _________________________
(please
provide middle name) First
Name Middle
Name Last
Name
Address
(Current) _______________________________________________________________________ City/State/Zip
__________________________________________________________________________ Where
Employed /Volunteering (Diocesan Location) ____________________________________________ City
____________________________________ Position _______________________________________ Have
you had a previous background check through the Diocese of Allentown?___Yes ___No *
* * * * * * * * * * * * * * * * * * * * * * * * ************************************************** Social
Date
Security
Number ________________________________ of Birth __________________________________
Driver's
State
License Number ________________________________ of License ________________________________ Previous
Address (Within the past five years) __________________________________________________ City/State/Zip
__________________________________________________________________________ Previous
Address (Within the past ten years) __________________________________________________ City/State/Zip
__________________________________________________________________________ I
hereby grant to the Diocese of Allentown permission to complete a Criminal Background
Check, to conduct a social security number verification and to complete a Motor
Vehicle Check, if applicable. I consent to the Diocese following these procedures,
making these inquiries and sharing this information with other Roman Catholic
Dioceses, as necessary. Signature_____________________________________________Date_____________________________ Any
questions regarding this form or its usage should be directed to William F. Wehbe,
Human Resources Generalist at (610) 871-5200, Extension 262.
Completed
form must be returned to the Pastor, Principal or Administrator who requested
its completion.
**Parish/School must retain this completed
form for employee/volunteer files.**
| 
