Election of the Rocky Mountain Synod Bishop

Response Form for Potential Nominees

Name:______Email: ______

Phone contact information: cell ______home ______work ______

I do not feel called to submit information as a potential nominee. I am providing contact information above if my name appears on the ecclesiastical (nominating) ballot at the assembly and I not be present to remove my name from consideration during the late afternoon on Thursday, April 26, 2012.Please return this page by mail, fax 303.733.0750, or scan/email to so it is received by January 31, 2012.

or

I amreturning this completed form by mail with my signatureand will emaila digital photograph to . I also am completing the biographical form. If you would like for the synod office to use a photo from a recent photo directory, please check here: ___

INFORMATION FOR BACKGROUND CHECK PURPOSES ONLY

Serving in a leadership position in the Rocky Mountain Synod requires a background check. Please give permission for a background check by providing the necessary information below and your signature.

First name ______Middle Name ______Last Name ______

Ethnicity ______Gender M F Date of Birth ___ / ___ / ___

Social Security # ______Driver’s License Number ______State______

Have you ever been convicted of a crime (other than minor traffic offenses)? Yes No

If Yes, then please explain charges. Also include the State, County, and Year the conviction(s) occured:

Other names you have used, including maiden name and the date(s) your name(s) changed:

Ex: John Smith - 10/24/1980, John Doe - 2/22/1986, John Deer - 5/20/2005

Please list all of your residential addresses for the past seven years, starting with your present address.

STREET CITYSTATECOUNTYZIP FROM TO

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___ Yes, I have read and agree to abide by the terms listed below. I authorize Rocky Mountain Synod ELCA and/or Oxford Document Management arid their agents to investigate my background in connection with my application for employment,appointment, election, or a volunteer position. I understand that this may include investigativeinquiries related to my driving, credit, criminal, civil, education, and employment experiences. I hereby release and hold harmless all persons, agencies or companies furnishing such information from liability and responsibility. A photo static/fax/electronic copyof this document can be substituted for the original. This document shall be valid for a periodof one (1) year from the date of my signature. I certify that this Authorization was completedby me and all information is true and complete to the best of my knowledge.

SIGNATURE ______DATE ______

ROCKY MOUNTAIN SYNOD, ELCA • 455 SHERMAN ST., SUITE 160 • DENVER, COLORADO 80203