I. APPLICANT INFORMATION

I, the undersigned, acknowledge that I have received and read the Disclosure Form regarding the background check to be conducted by Cincinnati Youth Collaborative (CYC) on behalf of __________________________________________________________ (referred to as "the Organization").

Full Legal Name: ____________________________________________________ (Please print clearly)

Any Other Names Used (e.g., Maiden Name, Aliases):

Date of Birth (MM/DD/YYYY): ________________________________________

Social Security Number: ____________________________________________

Current Address:

Street: ______________________________________________________________

City: _________________________ State: __________ Zip Code: ___________

How long is the current address? ________ years ________ months

Previous Addresses (if less than 7 years at current address):

Street: ______________________________________________________________

City: _________________________ State: __________ Zip Code: ___________

Dates Resided: From _________ To _________

Street: ______________________________________________________________

City: _________________________ State: __________ Zip Code: ___________

Dates Resided: From _________ To _________

Driver's License Number (if applicable to role): ________________________

State of Issuance: __________________________________________________

1. AUTHORIZATION

By signing below, I voluntarily authorize Cincinnati Youth Collaborative (CYC), as the consumer reporting agency, to conduct a comprehensive background check, including obtaining consumer reports and/or investigative consumer reports, on my behalf for [Insert Name of Client Organization, e.g., Mentoring Ministries].

I understand that the information obtained will be used to evaluate my qualifications and suitability for a volunteer mentor position with the Organization.

I authorize any person, business, or government agency to release information about me to CYC for the purpose of this background check, including but not limited to:

• Criminal history records (felony, misdemeanor, and sex offender registries)
• Driving records
• Public records

I understand that a copy of this Authorization may be valid as an original.

III. ACKNOWLEDGMENTS

• I understand that I have the right to request a copy of any report obtained by the Organization and to dispute the accuracy of any information in the report directly with CYC.
• I understand that information obtained may be re-disclosed by the Organization to individuals involved in the volunteer selection process.
• I understand that I may revoke this authorization at any time by providing written notice to ______________________________________________ and CYC. My revocation will not affect any information already disclosed prior to the receipt of my written revocation.

1. CERTIFICATION

I certify that all information provided in this form is true, accurate, and complete to the best of my knowledge.

Applicant's Signature: ______________________________________________

Printed Name: ______________________________________________________

Date: ______________________________________________________________