Background Check Consent and ReleasePersonal Information(Required) First Name Middle Name Last Name Previous Names Used Maiden/Different last name(s) used, or indicate N/A if you have no other names Current Address Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific Zip Address HistoryIf less than five (5) years at current address, provide previous address(es).From MM/YYYYTo MM/YYYYStreetCityStateZip Add RemoveContact InfoEmail AddressCell PhoneHome Phone Add RemovePersonal InfoDate of BirthSocial Security #Driver License #State Issued Add Remove*NOTE: The above information is required for identification purposes only, and is in no manner used as qualification for employment. Have you ever applied to LCCS before?Have you ever applied to LCCS before? Yes No If so, when?If so, when? Add RemoveAre you a former employee or alumni?Are you a former employee or alumni? Former Employee Alumni Both Background Investigation Consent I hereby authorize Lake Country Christian School and/or its agents to make an independent investigation which may include information regarding my background, references, criminal or police records, and Department of Motor Vehicle records, as part of the employment and/or volunteer process. At any time during the tenure of my employment or volunteer service, this report may be compiled by any source required to verify information that I have voluntarily supplied. I understand that I may request a complete and accurate disclosure of the nature and scope of the background verification, to the extent such an investigation includes information bearing on my character, general reputation, personal characteristics or mode of living. I consent to the background investigation.ReleaseI release Lake Country Christian School and/or its agents and any person or entity, which provides information pursuant to this authorization, from any and all liabilities, claims or lawsuits in regards to the information obtained from any and all of the above references or sources used. Release agreement.Background Investigation Consent and Release(Required)Applicant's Complete Legal Name (Print)Applicant's Signature or Electronic SignatureDate Add Remove Δ
