BACKGROUND CHECK DISCLOSURE AND AUTHORIZATION

Counselor & Staff Background Check Authorization Form

As part of the employment process, Lakewood Retreat will do Background Checks, which I understand may include information regarding my credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living.

AUTHORIZATION

During the application process and at any time during the tenure of my employment paid or volunteered with the Lakewood Retreat, I hereby authorize CampBackground Checks on behalf of Lakewood Retreat to procure a report which I understand may include information regarding my credit worthiness, credit standing, credit capacity, character, general reputation, personal characteristics, or mode of living. This report may be compiled with information from credit bureaus, courts record repositories, departments of motor vehicles, past or present employers and educational institutions, governmental occupational licensing or registration entities, business or personal references, and any other source required to verify information that I have voluntarily supplied. I understand that I may request a complete and accurate disclosure of the nature and scope of the background verification to the extent such investigation includes information bearing on my character, general reputation, personal characteristics or mode of living.

APPLICANT FIRST NAME, MIDDLE INITIAL, AND LAST NAME

First Name

Last Name

First Name, Middle Initial, and Last Name

APPLICANT ADDRESS

Address Line 1

Address Line 2

City

State

Zip

Applicant Phone Number

Applicant Email Address

Social Security Number - required for background identification purposes only

###-##-#### (Received at a secure email address terminal)

Applicant Date of Birth - for background identification only

Your submission of this form constitutes your authorization of the background check to be performed as described above.

Clicking the submit button below will send this form to a secure terminal at Lakewood Retreat for confidential processing. Any questions may be directed to Human Resources at Lakewood Retreat - 25458 Dan Brown Hill Rd - Brooksville, FL 34602. Phone 352-796-4097

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