Background Check | Pierce Church

First Name *

Middle Name *

Last Name *

Birthdate (MM/DD/YYYY) *

Please list any other legal names you've held

Race *

Gender *

Social Security Number *

Birthplace (Country) *

Birthplace (State)

Current Home Address (Line 1) *

Current Home Address (Line 2)

City *

State *

Zip / Post Code *

Country *

Phone *

Email

Have you ever been arrested for any crimes against children or other persons? *

Have you ever been found in any dependency action to have sexually assaulted or exploited any minor or to have physically abused any minor? *

Have you ever been found by a court in a domestic relations proceedings to have sexually abused or exploited any minor or to have physically abused any minor? *

Have you been convicted of the possession, use, or sale of drugs within the last seven years? *

Have you been released from incarceration for a conviction of the possession, use, or sale of drugs with the last seven years? *

Have you abused alcohol, legal, or illegal drugs within the past 30 days? *

Has your driver’s license been suspended or revoked with the last seven years? *

Have you ever been convicted of crimes relating to financial exploitation where the victim was a vulnerable adult? *

Have you ever been found by a court in a protection proceeding to have abused or financially exploited a vulnerable adult? *

Have you ever been licensed by a licensing board that licenses business / professionals? (If yes, please answer A and B below) *

A. Have you ever been found by that licensing board, or any other disciplinary board to have sexually or physically abused or exploited any minor or develop- mentally disabled person?

B. Have you ever been found by that licensing board, or any other disciplinary board, to have abused a vulnerable adult?

Reference 1: First Name *

Reference 1: Last Name *

Reference 1: Email *

Reference 1: Phone *

Briefly describe your relationship to this person *

Reference 2: First Name *

Reference 2: Last Name *

Reference 2: Email *

Reference 2: Phone *

Briefly describe your relationship to this person *