Fillable riminal Behavior and Sexual C Misconduct Declaration and

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riminal Behavior and Sexual C Misconduct Declaration and

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C
riminal Behavior and Sexual
Misconduct Declaration
and Authorization for
Background Check
In the spirit of concern for the safety of the Wesley community and that of the
congregations and agencies who partner with us in the Practice of Ministry and Mission
program, we require applicants to answer the following questions and to sign below
giving Wesley permission to conduct a criminal background check. Be assured that as a
seminary, we believe in repentance and renewal. Therefore we will not necessarily
decline an applicant on the basis of past criminal behavior. Applicants will not be
disqualified on the basis of their political actions or affiliations.
1. Have you ever been charged with a crime? Yes No
2. If “Yes,” were you found guilty? Yes No
3. Have you ever been accused of sexual misconduct or harassment with a
child, youth, or adult? Yes No
4. Have you ever been dismissed or resigned from any position, volunteer or
salaried, because of an accusation of criminal or sexual misconduct on your
part? Yes No
5. If you answered “Yes” to any of these questions, please explain your
understanding of the circumstances below. (Attach additional sheet of paper if
needed).
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Wesley Theological Seminary will conduct a background check for each applicant.
My signature below indicates that all the information contained in my application
is factually correct and honestly presented. I understand that false
representation may result in denial, revocation of admission, or separation from
the seminary. My signature also authorizes the seminary to complete a criminal
background check.
Signature______________________________________Date_______________
Both pages must be completed, signed and returned to the Admissions Office.
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Admissions ~ 4500 Massachusetts Ave., N.W., Washington, DC 20016 ~ (202) 885-8659 ~ Fax (202) 379-7051
AUTHORIZ
ATION TO RELEASE INFORMATION FOR
BACKGROUND CHECK
I, ___ __
Last Name First Name Middle Name
Current Address (include street, city, state, zip code) Dates Lived Here
Addresses for the Past Seven Years: (include street, city, state, zip code) Dates of Residence:
Date of Birth (mm/dd/yyyy) Other Names Used (including maiden name) Years Used
__
Gender:
Female Male
Social Security Number (xxx-xx-xxxx)
I do hereby authorize verification of all information in my admissions application. I also authorize a criminal
behavior and sexual misconduct check to be conducted by any duly authorized agent of IntelliCorp Records, Inc
to obtain, whether the said records are public or private, and including those which may be deemed to be
privileged or confidential in nature. I release all persons from liability on account of such disclosures.
Information appearing on this Authorization will be used exclusively by IntelliCorp Records, Inc for
identification purposes and for the release information which will be considered in determining any suitability
for admission. I certify that I have made true, correct, and complete answers and statements on my
admissions application, on any supplements to it and in any interview in the knowledge that they will be relied
upon in considering my application for admissions to Wesley Theological Seminary. I authorize without
reservation, any party or agency contacted by IntelliCorp Records, Inc to furnish the above-mentioned
information.
I have the right to make a request to IntelliCorp Records, Inc, upon proper identification, to request the nature
and substance of all information in its files on me at the time of my request, including sources of information,
and the recipients of any reports on me which IntelliCorp Records, Inc has previously furnished within the two
year period preceding my request.
I understand and agree that any omission, false statement, misleading statement, or answer made by me on
my application or any supplements to it and in any interviews will be sufficient grounds for rejection of
admission to Wesley Theological Seminary.
________________________________________
_______________
Printed Name Applicant Signature Date
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riminal Behavior and Sexual C Misconduct Declaration and

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Completed 15 March 2022

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