FORM A– PAID

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Name of Parish

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___________________________________
Address

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Telephone Number

Account No. T20 251 2340                                                                                  Date:___________________________________

This is a Non-Profit Organization pursuant to 501(c)(3) of the Internal Revenue Code.

The following named individual has made application with this organization for:

Employment:______________________________________________________________________

• Last Name of Applicant (please print):___________________________________
  
  
• First Name (please print):___________________________________
  
  
• Full Middle (please print):___________________________________
  
  
• Maiden, Alias or Former (please print):___________________________________
  
  
• Date of Birth (Month / Day / Year):___________________________________
  
  
• Sex (M or F):___________________________________
  
  
• Social Security Number:___________________________________

 

I authorize the State of Minnesota-Bureau of Criminal Apprehension to disclose all criminal history record information to The Diocese of St. Cloud for the purpose of employment or otherwise working within this organization.

The expiration of this authorization shall be for a period no longer than one year from the date of my signature.

 

Signature of Applicant _______________________________________ Date___________________

State of Minnesota
County of___________________________________

 

Subscribed and sworn to before me this
_________day of___________________________________, 2003.

Notary Public___________________________________

 

Notary Seal