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Employee/Volunteer Disclosure Statement for Potomac Valley Youth Association

Disclosure: Potomac Valley Youth Association will obtain one or more investigative consumer reports about you for insurance purposes. The reports will include information about your character, general reputation, personal characteristics, and mode of living. We will obtain these reports through a consumer reporting agency. Our consumer reporting agency is backgroundchecks.com (“BGC”). BGC’s address is P.O. Box 353, Chapin, SC 29036. BGC’s telephone number is (866) 265-6602. To prepare the reports, BGC may investigate your education, work history, professional licenses and credentials, references, criminal record, lawsuits, driving record, credit history, and any other records with public or private information sources. You may inspect BGC’s files about you (in person, by mail, or by phone) by providing identification to BGC. If you do, BGC will provide you help to understand the files, including trained personnel and an explanation of any codes. Another person may accompany you by providing identification. If BGC obtains any information by interview, you have the right to obtain a complete and accurate disclosure of the scope and nature of the investigation performed. The Federal Trade Commission provides a summary statement of your rights on its website at http://www.ftc.gov/credit.

Personal Information: Please print the information requested below to identify yourself for our agency.

Full Name
Street Address
City
E-mail
Telephone
Date of Birth
SSN

Describe your background Youth Sports (as Coach, Mgr., Official or other type):Include Position(s) Held, League/Team Name, Date(s), and City/State

Residence(s) for last 5 years

Have you ever been convicted of a crime? If yes, please explain.

By checking this box, I hereby verify that the information provided is true and correct. I further certify that I understand that the intent of Potomac Valley Youth Association is to deny a position to anyone convicted of a crime of violence or a crime against another person. I understand and agree that Potomac Valley Youth Association its affiliates may, in their sole discretion, decline to accept my application for volunteer/staff services with or without cause. I authorize: (a) BGC to request information about me from any public or private information source; (b) anyone to provide information about me to BGC; (c) BGC to provide PVYA one or more reports report based on that information; and (d) PVYAs to share those reports with others for legitimate business purposes related to your employment. I acknowledge that a fax, image, or copy of this authorization is as valid as the original. I make this authorization to be valid for as long as I am an applicant or employee with PVYA.