I hereby authorize Blueprint 58 to request and receive any and all background information about or
concerning me, including but not limited to my Criminal History, Social Security Number Trace including a
consumer report under the Fair Credit Reporting Act, 15 U.S.C 1681, Driving Record, Employment History,
Military Background, Civil Listings, Educational Background, Professional License from any Individual,
Corporation, Partnership, Law Enforcement Agency, and other entities including my Present and Past
Employers
The criminal history, as received from the reporting agencies, may include arrest and conviction data as well
as plea bargains and deferred adjudications and delinquent conduct as committed as a juvenile. I understand
that this information will be used, in part, to determine my eligibility for an employment/volunteer position
with this organization. I also understand that as long as I remain an employee or volunteer here, the criminal
history check may be repeated at any time. I understand that I will have an opportunity to review the criminal
history as received by client/agency and a procedure is available for clarification, if I dispute the record as
received. I also understand that the criminal history could contain information presumed to be expunged.
I further release and discharge Blueprint 58 and all of their Subsidiaries, Affiliates, Officers, Employees,
Contract Personnel, or Associates, from any and all claims and liability arising out of any request for
information or records pursuant to this authorization, procurement of an investigative consumer report and
understand that it may contain information about my character, general reputation, personal characteristics,
and mode of living, whichever are applicable.
I understand that I have the right to make written request within a reasonable period of time for additional
information concerning the nature and scope of the investigation. I acknowledge that I have voluntarily
provided the above information for employment/volunteer purposes, and I have carefully read and
understand this authorization.
By signing below I accept the role of helping my mentee develop his/her God given gifts and to bring the
Gospel to his/her attention and I will make the minimum contacts each month as outlined in the training.