Ministry Partner CBI Form

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Criminal Background Investigation

Protection of Confidential Data:
This is a secure site. The requested information will only be used for a background check to allow you to work with our children/youth programs. The information will be protected and not divulged to anyone other than the staff members processing the background check. Failure to complete the requested information will result in an inability to process a background check, and therefore preclude your working with our children/youth.

If you have any questions about this form, please call Sonja Haas, Human Resources Specialist, at 719.388.4925.

Please complete the following information:

Criminal Background Investigation Form

* Last Name  
* First Name (Full)  
Middle Name  
* Gender  
* Date of Birth (mm/dd/yyyy)  
* Social Security No.  
* Ethnicity  
* Address  
* City  
* State  
* Zipcode  
* Phone  
* Email  
* Name of ministry leader requesting you to complete this form (please be specific)  
* Area of Ministry  
If you chose "Other" in the previous question, please explain here:  

CBI Background Questionnaire

Question 1: Have you ever been convicted of a criminal offense (felony or misdemeanor, except for minor traffic violations)? You will need to answer "Yes" if you have entered into a plea agreement, including a deferred sentence, deferred prosecution, or deferred judgment arrangement, in connection with a criminal charge. If you have been convicted of such an offense, please give a statement or explanation below. Include nature of offense, date, court where conviction was entered, and any other relevant information. You need not disclose criminal convictions that are contained in sealed or expunged records.
* Question 1 (Yes/No)  

Question 2: Have you ever been charged with a sexual offense, offense relating to children, or crime of violence? If you have been charged with such an offense, please give a statement or explanation below. Include nature of offense charged, date, law enforcement agency making the charge, and any other relevant information. You need not disclose information contained in sealed or expunged records.
* Question 2 (Yes/No)  

Question 3: Have you ever been reported to a social services agency, law enforcement authority, child abuse registry, or similar organization, regarding abuse or misconduct involving children? If so, please provide a description of the circumstances with name and address of the entity receiving the report.
* Question 3 (Yes/No)  

Question 4: Have you ever been subjected to expulsion, reprimand, or other discipline by a church, denomination, or other religious organization? If so, please provide a description of the circumstances with name and address of the church, denomination, or religious organization involved.
* Question 4 (Yes/No)  

Question 5: Have you ever been dismissed from employment or a volunteer position, following an allegation of sexual misconduct or other immoral or inappropriate behavior or conduct? If so, please provide a description of the circumstances with name and address of the company or organization that dismissed you.
* Question 5 (Yes/No)  

Question 6: Have you ever been the subject of a civil lawsuit or an investigation or allegation of sexual misconduct, sexual harassment, or other immoral behavior or conduct, involving adults or children? If so, please provide a description of the circumstances with name and address of the employer, educational institution, church, or other organization where the lawsuit, investigation, or allegation arose or occurred.
* Question 6 (Yes/No)  

Description of offense from questions 1-6 (if applicable):  

* By checking this box I certify that the above information is accurate and complete.  

* By checking this box I give Woodmen Valley Chapel permission to process a background check.  

* Today's Date (mm/dd/yyyy)  
________________________________________________________________
Check this box if you are under the age of 18.  

By checking this box I certify that I am the Parent/Guardian of the above minor and the above information is accurate and complete.  

Full Name of Parent/Guardian and relationship to minor  

 


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