The Sparrow S Nest Maternity Home - Release of Background Information

The Sparrow’s Nest Maternity Home – Volunteer Application

The Sparrow’s Nest Maternity Home - Release of Background Information

In the interest of safety and security I, the undersigned applicant (also known as “consumer”), authorize THE SPARROW’S NEST, LLC through its independent contractor, LexisNexis, to procure background information (also known as a “consumer report and/or investigative consumer report”) about me, prior to, and at any time during, my service to the organization. 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 request to THE SPARROW’S NEST, LLC, 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. I release THE SPARROW’S NEST, LLC, their respective employees and LexisNexis, Inc., their agent and employees and all persons, agencies and entities providing information or reports about me from any and all liability arising out of furnishing any such information or reports.
PLEASE PRINT
Full legal name: / Date of birth:
Other names used: / SS#:
Driver’s license #: / State issued:
Daytime phone: / Gender: Male Female
Please note: If your address is a rural route or post office box we must have City and County to show mail was delivered.
Current address:
City: / County: / State: / ZIP:
How long at this address (months / years)?: /
Previous address:
City: / County: / State: / ZIP:
How long at this address (months / years)?: /
Applicant’s signature: / Date:

The Sparrow’s Nest, 6209 Mid Rivers Mall Dr. #119, St. Peters, MO 63376 - 636.336.2534 2 of 2

TSN-VA-2013-08.02.4 www.TheSparrowsNestSTL.org