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Today’s Date:
___________________________ ________________________ ______________________
Last Name First Name Middle Name
Please List Other Names Used _________________
Home Address
(If less than 2 years, please provide additional addresses below)
City County ____ State_ Zip Code_______
SSN D/L or State ID State Issued
Email Address
For identification purposes only, please provide full Date of Birth:
Home Address ________
City County State Zip Code_______
Home Address ________
City County ____State _ Zip Code_______
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In connection with your employment with New Life Christian School (the Company”), notice is
hereby given that a consumer report and/or investigative consumer report may be obtained from
a consumer reporting agency for employment purposes. These reports may contain information
about your character, general reputation, personal characteristics and mode of living, whichever
are applicable. They may involve personal interviews with sources such as your neighbors,
friends or associates. The reports may also contain information about you relating to your
criminal history, credit history, driving and/or motor vehicle records, education or employment
history, or other background checks.
You have the right, upon written request made within a reasonable time after the receipt of this
notice, to request disclosure of the nature and scope of any investigative consumer report
prepared by contacting the Company and Protect My Ministry 14499 N. Dale Mabry Hwy., Suite
201 South, Tampa, FL 33618; Phone: 1-800-319-5581. For information about Protect My
Ministry’s privacy practices, see The scope of this notice and
below authorization is not limited to the present and, if you are hired, will continue throughout
the course of your employment and allow the Company to conduct future screenings for
retention, promotion or reassignment, as permitted by law and unless revoked by you in writing.
By signing below I hereby authorize the obtaining of consumer reports and/or investigative
consumer reports by the Company at any time after receipt of this authorization and throughout
the course of my employment, if applicable.
Signature: __________________________ Date: _____________________________
Print Name: ________________________ Last Four Digits of SSN: _____________
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