Background Check Authorization Form
Please fill out this form to authorize WLBC to run a background check on you so that you can serve in our ministries with kids and teenagers.
Full Name
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Current Address, Date: Mo, Yr
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Previous Address, Date: Mo, Yr
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AE
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AP
AR
AS
AZ
BC
CA
CO
CT
DC
DE
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FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MH
MI
MN
MO
MP
MS
MT
NB
NC
ND
NE
NH
NJ
NL
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
PW
QC
RI
SC
SD
SK
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
YT
Previous Address, Date: Mo, Yr
*
--
AA
AB
AE
AK
AL
AP
AR
AS
AZ
BC
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MH
MI
MN
MO
MP
MS
MT
NB
NC
ND
NE
NH
NJ
NL
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
PW
QC
RI
SC
SD
SK
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
YT
Social Security Number
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Date of Birth
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Driver's License Number
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Email
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This address will receive a confirmation email
Phone
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Your Signature
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Today's Date
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Submit
Description
Please fill out this form to authorize WLBC to run a background check on you so that you can serve in our ministries with kids and teenagers.
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