FORM B – VOL.

___________________________________
Name of Parish

___________________________________

___________________________________
Address

___________________________________
Telephone Number

Account No. ___________________________________ 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:

Volunteer work:______________________________________________________________________

• 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 Mind Your Business, Inc. to disclose all criminal history record information to the Diocese of St. Cloud for the purpose of employment or otherwise volunteering 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