Background Check Release Form
This form authorizes Saint Matthew Lutheran Church to obtain background information and must be completed by the applicant. The church will keep this completed form on file for at least two years after requesting a background check.
I, the undersigned applicant (also known as “consumer”), authorize Saint Matthew Lutheran Church through its independent contractor, Protect My Ministry, to procure background information (also known as a “consumer report and/or investigative consumer report”) about me. This report may include my driving history, including any traffic citations; a social security number verification; present and former addresses; criminal and civil history/records; and the state sex offender records.

I understand that I am entitled to a complete copy of any background information report of which I am the subject, upon my written request to Saint Matthew Lutheran Church, if such is made within a reasonable time from the date it was produced. I also understand that I may receive a written summary of my rights under the Fair Credit Reporting Act upon my written request.

I agree with the above statement: *
(Please type full name)
Today's Date *
Identifying Information for Background Information Agency
(also known as "Consumer Reporting Agency")
Full Name *
First, Middle, Last
Other Names Used *
Alias, Maiden, Nickname
Current Street Address *
Current City *
Current State *
Current County *
Have you been at your current address less than two years? If yes, provide previous address information. *
Previous Street Address
Previous City
Previous State
Previous County
Identifying Information for Background Information Agency
(also known as "Consumer Reporting Agency")
Social Security Number *
Driver's License Number *
Driver's License State of Issuance *
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