MIKE DURFEE STATE PRISON

Non-Custody

WAIVER

St. Dysmas -- Worship Attendance Form

I authorize the Mike Durfee State Prison, or its representative, to obtain and review my criminal background and any other background information deemed necessary.

Signature__________________________________________________ Date ______________

Approval for completing background check (via phone) ___XX___ Yes ____ No

Church that you belong to: ____________________________________

Name and Signature of staff receiving information over the telephone.

___________________________________________________________ Date _____________

Reverend, William R. Greaver -- St. Dysmas Pastor – MDSP Volunteer Staff

BACKGROUND INVESTIGATION INFORMATION

Name: ________________________________________ Soc. Sec. #: ________-______-________

(First Name) (Middle Name) (Last Name)

Phone Number: (_______)_________-____________

All Previous/ Other Names Used: (For example - Maiden Name): ________________________

Date of Birth: ____/_____/______ Do you have a valid driver license? _____ Yes _____ No

Driver License #: _________________________________________ State: _______________

List all other states in which you have resided: ____________________________________________

Office Use Only:

Signature of Control Room Staff _____________________________ Date _______________

Approved: ____yes ____no

Signature/ Special Security __________________________________ Date _______________

Approved: ____yes ____no

Signature / Human Resources ________________________________ Date _______________

Approved: ____yes ____no

Signature / Warden or Designees ______________________________ Date ______________

Please return this form to Pastor Bill Greaver Fax: (605) 664-0066 OR pastorbill@iw.net