Background Screening Release Form For Employees And Volunteers
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1BACKGROUND SCREENING RELEASE FORM
FOR EMPLOYEES AND VOLUNTEERS
Confidentiality Notice: All information on this form is held in the strictest of confidence. The purpose of this information is to insure
the accuracy of information pertaining to the applicant.
PLEASE PRINT THE BELOW INFORMATION
Name: ________________________________________________ ____________________________ _______________________
Last
First
Middle
Address: ____________________________________________________________________________ ______________________
Street
County
Mailing Address (if different from above): _________________________________________________________________________
____________________________________________________________ ____________ __________________
City
State
Zip
Home Phone: _(__________)______________________________ Work Phone: _(__________)_____________________________
-
-
-
-
Social Security Number
Date of Birth
Month
Day
Year
Driver’s License Number:___________________________________________________________ State:______________________
Previous Address (if different from above): ________________________________________________________________________
______________________________________________________________ ____________ __________________
City
State
Zip
(Please check what applies) If you are currently employed by any Catholic Organization of the Diocese of Wheeling - Charleston
you will need to check the employee box.
Employee Where: _______________________________________________________________________
Volunteer Where: _______________________________________________________________________
Authorization to release criminal history information reports, private companies’ dishonesty, drug offense or violence reports,
or motor vehicle reports.
I hereby authorize the Diocese of Wheeling-Charleston to make inquiries to Screening One, a consumer reporting agency,
concerning my suitability and qualification; including any public record of any arrest or convictions for crimes of violence or
dishonesty; any incidents of employment dishonesty, retail theft, or other employment related acts of dishonesty, violence or drug
related offenses reported to Screening One.
I further authorize any governmental agency where such arrest or conviction information is on file, and Screening One, to
disseminate such report(s) to the Diocese of Wheeling-Charleston. During any period(s) while I may be employed by and/or
volunteer, I hereby authorize the Diocese of Wheeling-Charleston to make further like inquires to Screening One as the Diocese of
Wheeling-Charleston may, from time to time, deem necessary. I also hereby authorize Screening One to issue such reports in
response to the Diocese of Wheeling-Charleston’s inquiry. I waive any future notice with respect to the Diocese of Wheeling-
Charleston’s inquiries or with respect to such governmental agencies, Screening One’s, dissemination of any such report(s) to the
Diocese of Wheeling-Charleston, and hereby generally release and fully discharge the Diocese of Wheeling-Charleston and Screening
One from and against any and all liability with respect to, or arising from, the release or dissemination of any such information for
such purposes.
I understand and agree that my involvement with the Diocese of Wheeling-Charleston: its Parishes, School, Diocesan Institutions
and Diocesan Services, may be determined, in whole or in part, based on the report(s) so issued to the Diocese of Wheeling-
Charleston by Screening One. I have been informed and I understand that I may request a copy of such report and that I may dispute
the accuracy or completeness of the information reported to the Diocese of Wheeling-Charleston by writing or calling the employer of
Screening One and requesting a copy of the report.
(X) ___________________________________________________________________________
_______________________
Signature
Date
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