Episcopal Diocese of Nebraska Parish Background Check Request Form
Parish Name and Location ___________________________________________________ Individual’s Name on whom the background check is to be conducted: (List any previous names, i.e. maiden name) Please print or type. __________________________________________________________ Parishioner: No___ Yes___ _____Consent form attached. Please conduct the following background checks on this individual: (check all that apply) _____Criminal records check and Social Security trace--$9.00 _____Credit check--$9.00 _____Driving record check--$9.00 each for Nebraska, Missouri, South Dakota, Minnesota, Colorado and Wyoming. Iowa--$14.00; Kansas $12.00 (Circle the state(s) desired. Contact Sue Renniger (srenniger@episcopal-ne.org) for fees for other states. Total cost of desired background checks___________________. Check enclosed. For Employment____ For Volunteer position ____
(Nebraska motor vehicles checks cannot be run on volunteers.)
______________________________________________________________________ Rector/priest-in-charge (please print) ______________________________________________________________________ Signature of the rector, priest-in-charge Date
Please include a check for the total amount made out to the Diocese of Nebraska and send to Background Check , Diocese of Nebraska, 109 N. 18th St., Omaha, NE 68102. Rev. 3/6/08