VITA Volunteer Background Check Form

If you are a new volunteer, please complete the entire background check form and make sure to submit. This is not required for returning VITA volunteers. Please note if you are a new volunteer we cannot consider your application without the VITA Volunteer Application.

The information required within this Background Check Form is secure and is required by law enforcement agencies and other entities for positive identification purposes when checking public records. It is confidential and will not be used for any other purposes. By completing this Background Check form, you are releasing United Way of Kenosha County and agents and all persons, agencies, and entities providing information or reports about you from any and all liability arising out of the mentioned information or reports.

If you have any questions, please contact us at unitedway@kenoshaunitedway.org or call 262-658-4104.

Thank you.

Date

First Name

Middle Name

Last Name

Please enter other names you have used

Home Address

City

State

Zip Code

Email address

Phone Number

DOB

Gender

Race

Drivers License Number

Please include spaces and/or dashes

State Issuing License

Full Name as it appears on license

Consumer Report Release Authorization

In connection with my volunteer service with the Volunteer Income Tax Assistance (VITA) Program, I understand that a consumer report or an investigative consumer report may be requested. I understand that you may be requesting information from public and private sources about my criminal record and social security validation.

I acknowledge that an electronic copy or photographic copy shall be as valid as the original. The release is valid for most federal, state, and county agencies.

I certify that the information stated in this volunteer application is true to the best of my knowledge

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