Diocese of Scranton Background Check Application (please print clearly) Full Legal Name: (Must match SS#) (First) (Middle) (Last) City/State/Zip: Telephone Number: (area code + number) ‐ ‐ Gender: Male Address: Date of Birth: Month/Date/Year Social Security Number: Female Name of the Parish/School where this Background Check is needed: Town: This Background Check is needed because you are: (please check the box that applies to your status or membership) Parish/School Volunteer Parish/School Employee Diocesan Employee Clergy Deacon Religious Candidate for Ordination Other: (name of organization or entity) In accordance with the Charter for the Protection of Children and Young People, the Diocese of Scranton has a Safe Environment Coordinator, whose job it is to make certain dioceses and eparchies, parishes and schools create and maintain safe environments through screening and training programs. In doing so, a background check must be completed on all diocesan clergy members, employees and volunteers who work with children. Therefore, the purpose of this Application is to authorize the Diocesan Child Protection/Safe Environment Office to conduct a background check on the applicant. Applicant Signature: Date: Please make check or money order payable to: Diocese of Scranton. Cost is $9.00 per applicant. Mail the completed application form with payment to: Diocese of Scranton Attn: Kathy Bolinski 300 Wyoming Avenue Scranton, PA 18503 The completed clearance will be sent directly to the Parish/School indicated. For additional information on the Diocesan Child Protection/Safe Environment Office or the Charter for the Protection of Children and Young People, visit the Diocesan website at: www.dioceseofscranton.org and click on Child Protection/Safe Environment Office. 7/2013 KJB