Volunteer Background Information

First Name: ^*

Last Name: ^*

Zip Code: ^*

Any Other Names Used:

Date of Birth: ^*

Enter your date of birth in this format: mm/dd/yyyy

Social Security Number: ^*

Email Address

Provide if you prefer to receive information via email.

Mailing Address: ^*

Apartment/Unit#:

City ^*

State*:

Driver's License State:

D.L. Number:

Address on D.L.:

Name of High School, College, University or Institution of Professional Training where you completed the highest level (GED – provide state):

Campus Name:

Campus City and State:

Name on GED or under which you graduated:

Year(s) Attended:

Year Graduated/GED Completed:

Name as it appears on License/Certification/ Registry:

Type:

State/Region or Issuing Organization:

Country:

Number:

Type:

State/Region or Issuing Organization:

Country:

Number:

*Have you ever been convicted of a crime? (Please attach a separate sheet of paper to provide additional entries)

Yes

Offense:

County:

State:

When:

Offense:

County:

State:

When:

Offense:

County:

State:

When:

Offense:

County:

State:

When:

City:

State:

Date From:

Date To:

City:

State:

Date From:

Date To:

City:

State:

Date From:

Date To:

City:

State:

Date From:

Date To:

Minnesota or Oklahoma applicants or employees only: Please mark an X in the designated field if you would like to receive a free copy of a consumer report if one is obtained by the Company. The report will be mailed to the current address you indicated on this form. ^*

Yes, I have read.

California applicants or employees only: Please mark the following field if you would like to receive a copy of an investigative consumer report or consumer credit report at no charge if one is obtained by the Company whenever you have a right to receive such a copy under California law. The report will be mailed to the current address indicated above ^*

Yes, I have read.

California applicants or employees only: By marking an X in the designated field, you will receive and are acknowledging receipt of the NOTICE REGARDING BACKGROUND INVESTIGATION PURSUANT TO CALIFORNIA LAW. ^*

Yes, I have read.

New York applicants or employees only: You have the right to inspect and receive a copy of any investigative consumer report requested by the Client by directly contacting PreCheck Inc. Additionally, please mark this field to receive and acknowledge receipt of a copy of Article 23-A of New York Correction Law. ^*

Yes, I have read.

Maine applicants or employees only: Under Chapter 210 Section 1314 of Maine Revised Statutes, you have the right, upon request, to be informed within 5 business days of such request of whether or not an investigative consumer report was requested. If such report was obtained, you may contact the Consumer Reporting Agency and request a copy.

Massachusetts applicants or employees only: If you ask, you have the right to a copy of any background check report concerning you that the Company has ordered. You may contact the Consumer Reporting Agency for a Copy.

Washington State applicants or employees only: You have the right, upon written request made within a reasonable period of time after your receipt of this disclosure, to receive from the Company a complete and accurate disclosure of the nature and scope of the investigation we requested. You also have the right to request from the consumer reporting agency a written summary of your rights and remedies under the Washington Fair Credit Reporting Act.

I have read and understand the above information and assert that all information provided by me is true and accurate.

Your Full Name ^*

Today's Date ^*

Please enter date in this format: mm/dd/yyyy

Volunteer Information

Education

State Law Notices

Additional Requirements