DISCLOSURE AND AUTHORIZATION FOR RELEASE OF INFORMATION
I understand that in connection with my volunteer application, Girl Scouts Western Pennsylvania (“GSWPA”) and/or
Intellicorp.net, their agents, assigns or any other authorized third parties (collectively, the “Investigators”) may be performing,
requesting, obtaining or conducting one or more background checks on me. These background checks which may be performed
at any time and must be performed every 3 years, may include an inquiry into my employment history, education, general
character or reputation, work experience, driving, criminal and credit histories and such other information (“Information”) as may
be required.
I understand GSWPA may rely on any part or all of this Information in determining whether to extend a volunteer opportunity to
me.* I further understand that if any adverse action is taken by GSWPA or if GSWPA chooses not to extend a volunteer position
to me based upon the Information, that I will be provided a summary of my rights under the Fair Credit Reporting Act.
GSWPA will not provide any Information collected for this purpose with outside groups. All Information received by GSWPA
remains Confidential.
I have read this disclosure and authorization for release of information and by signing below, I hereby authorize Investigators to
conduct a background check as described herein in conjunction with my volunteer application. I hereby release Investigators
from any and all liability related to the procurement or disclosure of any Information provided by me or obtained about me in
connection with my application for a volunteer position with GSWPA. I further direct and authorize Investigators to conduct the
background check and further authorize any third parties who may be the custodians of or in possession of the requested
Information to disclose such Information to Investigators in connection with this background check.
_____________________________________________
Applicant Signature
____________________________________
Date
Printed name:
Gender
____________________________________
Social Security Number
Date of Birth:
_____________________________________________
Month
Day
Year
____________________________________
Other Names Used
_______________________________________________________
First
Middle
Last
(Including maiden name)
Address for the Past Seven Years: (If you lived outside of Pennsylvania any time in the past 20 years, please also
provide the most recent out of state address).
__________________________________________________________________________
Street
City
State
__________________________________________________________________________________________
Street
City
State
__________________________________________________________________________
Street
City
State
___________
Zip
___________
Zip
___________
Zip
*Note: A conviction record will not necessarily be cause for disqualification. All background information will be strictly confidential.
6/2013
www.gswpa.org
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