Release and Authorization Form

In connection with my application for employment or volunteer service, I understand that Holy Cross Lutheran Church and School may request information regarding my motor vehicle record, credit history, and criminal background from various state, national, and public sources, including Central Registries for Child Abuse and other publicly available records.

RELEASE AND AUTHORIZATION

Name(Required)

Prefix First Middle Last

Maden Name

Married names, nicknames or other names used: (list “None” if none apply)(Required)

Date of Birth(Required)

Race(Required)

Phone(Required)

Email(Required)

Driver’s License Number:(Required)

State Issued:(Required)

Social Security #(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

6 0 0 N . G R E E N W I C H R O A D W I C H I T A , K A N S A S 6 7 2 0 6 – 2 6 3 3

3 1 6 ) 6 8 4 – 5 2 0 1 ( C H U R C H )

( 3 1 6 ) 6 8 4 – 4 4 3 1 ( S C H O O L )

( 3 1 6 ) 6 8 4 – 2 8 4 7 ( F A X )