2020 Peninsula Optimist Club Member Background
Important – Please read carefully before proceeding

In connection with your volunteer, application or temporary agency / contractor assignment with Peninsula Optimist Club (POC), we may upon execution of this authorization, investigate the information contained in this form, your application and other relevant background information to determine whether you are a suitable candidate for employment, promotion, position re-assignment or contract. Therefore POC will request a consumer report or investigative report as defined under applicable state and federal law from a third party agency, Virtus Group Investigations. The scope of the report requested by POC may include information relating to your criminal history, driving history, employment history, social security number verification, general reputation, personal characteristics and address history. The purpose of the background is solely to determine your employment eligibility. If you do not authorize POC to conduct your background check, you will not be considered for volunteer assignment, promotion, position re-assignment or contract.
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Email *
Full Legal Name (First, Middle, Last) *
Social Security Number: *
Date of Birth: *
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Please list your last 2 address, starting with the most current. *
Have you ever been convicted of any crime or do you have any pending criminal cases against you?  If you answer NO, skip the next question. *
Please List the Date, Charge, State if you answered Yes in the previous question.
I understand that I am required to pay a non-refundable $10.00 in addition to completing this form.   *
Required
I acknowledge receipt of this background investigation authorization, as set forth above, and certify I have read and understand these disclosures. I authorize POC or its representative to obtain an investigative consumer report as defined under state and federal law or other background information used in connection with POC consideration for my volunteer assignment, promotion, re-assignment or contract. I acknowledge that a scanned, photocopied or emailed copy of this release shall be as valid as the original. This authorization is valid for any federal, state, county and local agencies or authorities. I understand I have the right to make a written request within 30 days after receipt of this notice for complete and accurate disclosure of information concerning the nature of this investigation. I certify that all my answers on this authorization and true and complete. I understand that falsification; omission or misrepresentation of fact on this authorization may be cause for denial of employment or immediate termination of employment, if hired, regardless of when and how discovered. *
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