Volunteer Name *

First Name

Last Name

Birth Date *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

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Background Check Authorization *

I hereby authorize Junction City Church of the Nazarene to obtain and/ or request information about my background and criminal history. I authorize the release of information regarding any record of charges or convictions contained in its files, or in any criminal file maintained on me at the local, state, or national level. I do release said entities from all liability that may result from any such disclosure made in response to this request.

Yes, I have read the above authorization and I agree