Church Knights Information/Verification Release Full Name(Required) First Last Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone(Required)Date of Birth(Required) MM slash DD slash YYYY Authorization and ReleaseHaving filed an application for employment/paid or volunteer with LIFEPOINT MINISTRIES, INC., I do hereby request and consent to have an investigation made as to my character, professional reputation and general fitness for the position I have applied for, now or at any time during my employment, and to verify the accuracy of the information supplied on my application, and such other information as may be received, all of which will be reported to my prospective employer, I hereby agree to give any further information, which may be required, concerning my past record. I understand that the contents of my background report are confidential. I will be given a copy if l so request. I also authorize, and request, every person, firm, company, previous employer, corporation, governmental agency, law enforcement agency, court, association or institution having control of any documents, records or other information pertaining to me, to furnish to Pasquale Imbimbo, Church Knights, as agent for my prospective employer, any such information, including documents, records, and files, whether formal or informal, pending or closed, or any other pertinent data; and to permit my prospective employer, or any of its agents or representatives to inspect and make copies of such documents, records, files or other information. I also understand and agree that neither my employer, nor its agent(s), is responsible for the accuracy of the content of any records located by, or delivered to, them by any entity. I hereby release, hold harmless, discharge and exonerate its agents or representatives and any person, so furnishing information, from any and all liability, of every nature and kind, arising out of the furnishing or inspection of such documents, records, files and other information or the investigation made by Pasquale Imbimbo, Church Knights or it's agents. I have read the foregoing document and I have answered all questions with respect to my application for a background report fully and frankly. The answers are complete and true and I affix my signature hereto freely and voluntarily. COPIES OF THIS DOCUMENT SHALL CARRY THE SAME AUTHORITY AS THE ORIGINALApplicant Signature(Required)Witness/Employer Signature(Required)Date(Required) MM slash DD slash YYYY ATTENTION: The Global Ministry Center Department Director or Supervisor, Conference Bishop, Any Church Pastor or Administrator is responsible and required to maintain this document on file as per the usage agreement with Pasquale Imbimbo, Church Knights. A separate document needs to be generated for each background check requested. ATTENTION: For the purpose of this document, employment means, paid or unpaid employment, full-time or part-time, volunteer or employee.
