Volunteer Application Form

!BGCS_DK

OF MIDDLE TENNESSEE

Administrative Office

1704 Charlotte, Suite 200

Nashville, Tennessee 37203

Telephone (615) 833-2368

Fax (615) 833-4381

Background Check Authorization Form

NAME (Please Print) __________________________________________________________________

Last First Middle (required)

Maiden Name or Other Alias Names: ______________________________________________________

Please List Addresses & Dates for the Past 7 Years:

Current: ____________________________________________________________________________

Previous:____________________________________________________________________________

Social Security Number:____________________ Drivers License Number:______________________

*Date of Birth: _____/______/______ Telephone Number:_________________________

*The above information is required for identification purposes

only, and is in no manner used as qualifications for employment.

RELEASE

I hereby authorize Boys & Girls Clubs of Middle Tennessee to make an independent investigation of my background, references, character, past employment, education, criminal or police records, including those maintained by both public and private organizations and all public records for the purpose of confirming the information contained on my application and/or obtaining other information which may be material to my qualifications for employment.

I release Boys & Girls Clubs of Middle Tennessee and any person or entity which provides information pursuant to this authorization, from any and all liabilities, claims or law suits in regard to the information obtained from any and all of the above referenced sources.

I understand that any offer or continuation of employment is contingent on a satisfactory background investigation. I also understand that this form will be kept in my permanent file if I am employed. I certify that the following is my true and complete legal name and all information contained herein is true and correct to the best of my knowledge.

Signature:_________________________________________________ Date:________________________