Background Verification - Disclosure and Authorization
Please mail or fax Authorization Form to: Diocesan Deployment Office
Diocese of CNY, 1020 7th North St., Suite 200, Liverpool, NY 13088
Fax: 315-478-1632
As part of the Episcopal Diocese of Central New York’s Professional Conduct Policy, the Diocese has
adopted a policy that a background investigation is required for all clergy, youth workers, and lay employees
over the age of 18 years working for the Diocese or in one of its parishes. The Fair Credit Reporting Act as
amended by the Consumer Reporting Reform Act of 1996 requires that we advise you that for purposes of
either paid or volunteer employment only, a Consumer Report, including information regarding any record of
charges or convictions in any criminal file maintained by local, state, or national criminal files, may be made
which shall include information as to your character, general reputation, personal characteristics or mode of
living. The Report may also include credit worthiness, credit standing, and credit capacity. Upon written
request, additional information as to the nature and scope of the report, if one is made, will be provided, in the
event the Report contains information regarding your character, general reputation, personal characteristics, or
mode of living.
I hereby authorize the Diocese of Central New York, or one of its parishes, to procure a Consumer
Report, which I understand may include information regarding my character, general reputation,
personal characteristics or mode of living. I understand that I may request a complete and accurate
disclosure of the nature and scope of the investigation; to the extent such investigation includes
information bearing on my character, general reputation, personal characteristics or mode of living.
Purpose of this Background Investigation: _________Working with youth______________
Parish or Group Requesting Investigation: ________ Happening ______________________
NAME: ________________________________
DATE: __________________________
________________________________________
All other names applicant has used
________________________________
County of Residence
_________________________
Address: Street Number
________
State
____________
City
__________________
Zip Code
________________________________
Applicant/Employee Signature
____________________________
Date of Birth of Applicant
_________________________________
Social Security Number
_____________________________
Home Telephone Number
PLEASE CHECK BELOW IF THE REPORT SHOULD INCLUDE THE FOLLOWING:
_________ INCLUDE a Credit Report as part of this background investigation.
___X____ INCLUDE a motor vehicle report (for people who will transport members of parish/group
to church sponsored events):
________________________
__________________
____________________
Driver’s License Number*
License Expiration Date
State Issuing License
*Please attach a copy of your Driver’s License