PENTECOSTAL CHURCH OF GOD (Incorporated)

	    Oregon/So. Idaho	 (District)
BACKGROUND INVESTIGATION CONSENT

I                                       hereby authorize the Oregon/So. Idaho District of the PCG
and/ or its agents to make an :independent investigation of my background, references, character, last 
employment, education, credit history, criminal or police records, including those maintained by both the 
public and private organizations and all public records for the purpose of confirming the information 
contained on my Application and/ or obtaining other information which may be material to my 
qualifications for credentials now and, if applicable, during my tenure with the Pentecostal Church of 
God (Incorporated). 

I release the Pentecostal Church of God (Incorporated) and/or its agents and any person or entity, 
which provides information pursuant to this authorization, from any and all liabilities, claims or law 
suits in regards to the information obtained from any and all of the above referenced sources used. 

The following is my true and complete legal name and all information contained herein is true and 
correct to the best of my knowledge: 

Printed Name: First:                              Middle:                         Last:                              

Street Address:                                                                                               

City:                                             State:                     Zip:                              

Social Security Number:                                

Date of Birth:

Phone Number:

	Email Address: 

	Driver’s License Number: 

Applicant Signature:                                                         Date:                          

*NOTE: The above information is required for identification purposes only. 

CA, MN & Oklahoma Residents please note: In connection with your application, your credit 
report will be obtained and reviewed. Under CA & MN law, you have a right to receive a free copy Of 
your credit report by checking the appropriate box below. Your credit report will be mailed to you 
by the credit bureau. Under Oklahoma law, you have the right to receive a free copy of your 
consumer report. 

_ YES, I am a California resident and would like a free copy of my credit report; or 
_ YES, I am a California resident and would like a free copy of my investigative consumer report. 
_ YES, I am a Minnesota resident and would like a free copy of my consumer report. 
_ YES, I am an Oklahoma resident and would like a free copy of my consumer report. 

District office please note: If the consumer checks "Yes" regarding the consumer report, or if a CA I 
consumer checks "Yes" regarding the credit report (and you do request a credit report, please fax this 
form to your ChoicePoint service center. If consumer checks "Yes" regarding the full consumer report, 
and consumer resides in CA, you will need to provide the individual with a copy of their consumer 
report. 

Account Number: 

REV 2022 DJW