Background Check

Each participant in a Hope on the Ground short-term team must complete this form prior to their time in country.

By submitting this form, you consent to be the subject of a background check that Hope on the Ground will run on your behalf.

Team Name

PERSONAL INFORMATION

Name (as on passport)

First Name

Last Name

List any other names previously used.

Including maiden name, if married.

Date of Birth

YYYY

Current Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

CRIMINAL HISTORY

Have you ever been committed of a sex-related crime?

Yes

Have you ever been convicted of a crime involving violence or threat of violence?

Yes

Have you ever been convicted any other crime (including traffic crimes) except a minor traffic violation?

Yes

Have you ever been arrested within the last three years for a crime for which there has not yet been an acquittal or dismissal?

Yes

Please explain any "yes" responses.

DIGITAL SIGNATURE