REQUEST FOR CRIMINAL RECORDS CHECK AND AUTHORIZATION

I hereby request Choice Point/Volunteer Select to release any information which pertains to any record of convictions contained in its files or in any criminal files maintained on me whether local, state, or national.  I hereby release Choice Point/Volunteer Select from any and all liability resulting from such disclosure.

___________________________             Record Check Sent To:

Signature                                                  Dayspring Ministries

                                                                   International

                                                                   P.O. Box 3634

___________________________             Brookhaven, MS  39603

Print Name                                                  Attn: Dr. Gary Barkman

                                                                   President

                                                                   CONFIDENTIAL

___________________________

Print Maiden Name (If Appoicable)

___________________________

Print All Aliases

___________________________      

Date of Birth                                                                         

___________________________

Place of Birth

___________________________         

Social Security Number

___________________________                        

Today’s Date

The above signed does authorize the release of any of his/hers records to Dayspring Ministries International, P.O. Box 3634, Brookhaven, Mississippi  39603.