Bsa Application Details

The Boy Scouts of America (BSA) offers programs and activities for young men and women of all ages. Boys and girls can join Scouting through their school, faith-based organization, or community group, as well as on their own. In order to become a registered member of the BSA, an adult applicant must complete and submit a BSA Adult Application. This article provides detailed instructions on how to fill out the application form. After reading this post, you'll know exactly what information is required and where to submit your application.

This article offers details about bsa adult application. It's definitely worth making the effort to read through this before starting filling in your document.

QuestionAnswer
Form NameBsa Adult Application
Form Length10 pages
Fillable?Yes
Fillable fields117
Avg. time to fill out25 min 58 sec
Other namesboys scouts of america adult application, adult application, bsa adult application form, boy scout adult application

Form Preview Example

ADULT APPLICATION

This application is also available in Spanish. Esta solicitud también está disponible en español.

Your participation in the BSA can help youth become better citizens.

Adult leaders serve as important role models for youth in the BSA and this application aids the chartered organization

in selecting qualified adult volunteer leaders.

Youth Protection Training

All adult applicants are required to take this training in order to complete the adult application process. Go to my.Scouting.org to create an account and take the training online or contact your local council for classroom training. Include a copy of your completion certificate with this application.

Mission

The mission of the BSA is to prepare young people to make ethical and moral choices over their lifetimes by instilling in them the values

of the Scout Oath and Scout Law.

Criminal Background Check*

In order to complete the adult application

process, you will need to review the different disclosures that have been separately provided to you. The separate authorization form must be signed and returned when you submit your application.

Excerpt From the Declaration of Religious Principle

The BSA maintains that no member can grow into the best kind of citizen without recognizing an obligation to God and, therefore, recognizes

the religious element in the training of the member, but it is absolutely nonsectarian in its attitude toward that religious training. Its policy is that the home and organization or group with which the member is connected shall give definite attention to religious life. Only persons willing to subscribe to these precepts from the Declaration of Religious Principle and the Bylaws of the BSA shall be entitled to register.

*The three different background check forms must be torn off and each separately given to the applicant.

SKU 655528

524-501

2020 Printing

02/2020

Leader Requirements

The BSA is open to all who meet the requirements, and leaders are selected based on individual merit. Adult leaders must possess the moral, educational, and emotional qualities that the BSA deems necessary for positive leadership to youth. They must also:

Abide by the Scout Oath, Scout Law, and Scouter Code of Conduct. The Scouter Code of Conduct can be found at www.scouting.org/health-and-safety/gss/bsa-scouter-code-of-conduct/.

Subscribe to the precepts of the Declaration of Religious Principle.

Reside within the USA or a U.S. territory, or be a U.S. citizen residing outside the USA.

Be 21 years of age or older for primary leadership positions.

Be 18 years of age or older for assistant leadership positions.

Complete Youth Protection training (YPT) before application is processed and renew training as required by going to my.Scouting.org and creating an account.

Review the disclosure information related to the BSA’s background check process and complete and sign a Background Check Authorization form.

Take leader position-specific training at my.Scouting.org. Classroom training may also be available through your local council.

APPROVAL REQUIRED—UNIT ADULTS

Chartered organization head or chartered organization representative. The chartered organization representative is approved by the head of the chartered organization. All other adult leader applications must be accepted and approved by the head of the chartered organization or the chartered organization representative.

APPROVAL REQUIRED—COUNCIL and DISTRICT ADULTS Scout executive or designee must accept and approve all council and district adults.

Scout executive or designee must approve any adults who answer “yes” to any Additional Information question.

The adult leader application process will not be complete until Youth Protection training has been completed and a criminal background check has been obtained.

Health information. You should inform your unit leadership of any condition that might limit your participation. Before participating in activities with your unit, please fill out the Annual Health and Medical Record, No. 680-001, found on www.scouting.org/forms and provide it to your unit leadership.

Scouting magazine. All registered, paid adult leaders receive Scouting magazine; $2 of the registration fee is for the subscription.

Boys’ Life. Registered adults get a special rate. For a subscription to a magazine that helps children grow in the Scouting program, just fill in the Boys’ Life circle on the application and pay the subscription price.

The annual national registration fee is nonrefundable.

BSA Privacy Policy

The BSA protects the confidentiality of the names and personal information of those who are affiliated with the organization. No commercial or unauthorized use is made of the names, addresses, and other confidential information. The BSA and its affinity groups may use registration information to notify registrants of benefit opportunities.

For general questions, contact your local BSA council.

What Is the BSA Program?

The BSA program is outlined in the official publications of the BSA. Activities that are not in these BSA publications are not a part of the Scouting program. Leaders must not allow youth members or program participants to engage in any unauthorized or prohibited activities.

Training for New Leaders

The BSA is committed to your success as a volunteer while serving young people. To help you be successful there are training materials designed for you. Training resources are available through your local council and at my.Scouting.org.

What Makes a Trained Leader?

You are considered a trained leader when you have completed leader position-specific training for your position and have current Youth Protection training.

Youth Protection Begins With You™

Child abuse is a serious problem in our society, and unfortunately, it can occur anywhere, even in Scouting. For that reason, the BSA continues to create barriers to abuse beyond what have previously existed in Scouting.

The BSA is committed to providing a safe environment for young people. All adult leaders must complete Youth Protection training as part of the registration process and renew their training as required. It is highly recommended that parents who participate in Scouting activities complete YPT. To learn more about the BSA’s Youth Protection resources, go to www.scouting.org/training/youth-protection/.

Mandatory Reporting

All persons involved in Scouting must immediately report to local authorities any good-faith suspicion or belief that any child is or has been physically or sexually abused; physically or emotionally neglected; exposed to any form of violence or threat; or exposed to any form of sexual exploitation including the possession, manufacture, or distribution of child pornography, online solicitation, enticement, or showing of obscene material. No person may abdicate this reporting responsibility to any other person.

Additionally, any known or suspected abuse or behavior that might put a youth at risk must also be reported to the local Scout executive or the Scouts First Helpline (1-844-SCOUTS1 or 1-844-726-8871) if your Scout executive or local council cannot be reached.

Youth Protection Policies

Two registered adult leaders 21 years of age or over are required at all Scouting activities, including meetings. There must be a registered female adult leader over 21 in every unit serving females.

A registered female adult leader over 21 must be present for any activity involving female youth.

One-on-one contact between adult leaders and youth members is prohibited both inside and outside of Scouting.

These and other key Youth Protection policies are addressed in the training and at www.scouting.org/ training/youth-protection/.

To learn about the BSA’s other health and safety policies, please review the online version of the Guide to Safe Scouting, the Scouter Code of Conduct, and the Sweet Sixteen of BSA Safety, which are available at www.scouting.org/health-and-safety.

Scout Oath

On my honor I will do my best to do my duty to God and my country and to obey the Scout Law; to help other people at all times; to keep myself physically strong, mentally awake, and morally straight.

Scout Law

A Scout is trustworthy, loyal, helpful, friendly, courteous, kind, obedient, cheerful, thrifty, brave, clean, and reverent.

Please print one letter in each space.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BSA ADULT APPLICATION

 

 

 

 

 

 

 

 

First name (Full legal name)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Middle name

 

 

Last name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Suffix

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Preferred nickname:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Country

 

Home address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State

 

 

Zip code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Primary phone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Alternate phone

 

 

 

 

 

Ext.

 

 

 

 

 

 

 

Date of birth (mm/dd/yyyy)

 

 

 

 

 

 

 

 

All questions MUST be answered.Write NONE if applicable.

1.

Scouting background.

 

 

Position

Council

Year

 

____________________________________

 

____________________________________

 

____________________________________

2.

Experience working with youth in other

 

organizations. Please provide contact information.

 

____________________________________

 

____________________________________

 

____________________________________

3.

Previous residences (for last 10 years).

 

City

 

State

 

 

 

 

-

 

 

 

 

 

-

 

 

 

 

 

 

 

 

 

 

Ethnic background:

Native American

Black/African American

Caucasian/White

Hispanic/Latino

 

 

 

Social Security No. (required)

 

 

 

 

 

 

 

 

-

 

 

 

 

 

 

-

 

 

 

 

 

 

 

 

X

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Alaska Native

Asian

Driver’s license No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pacific Islander

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Occupation

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer

/

State

/

Gender

M F

 

_______________________ ____________

 

_______________________ ____________

 

_______________________ ____________

4.

Current memberships (religious, community,

 

business, labor, or professional organizations).

 

____________________________________

 

____________________________________

 

____________________________________

5.

References. Please list those who are familiar with

-

 

 

-

 

 

 

 

your character. References may be checked.

Name___________________________________

Telephone (_____)_________________________

Country

Business address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Position code

 

Scouting position title

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Email address

Work

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Select one)

Home

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State

 

 

 

Zip code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Are you an Eagle Scout? Date earned (mm/dd/yyyy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No

 

 

/

 

 

 

 

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Boys’ Life

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

subscription

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name___________________________________

Telephone (_____)_________________________

Name___________________________________

Telephone (_____)_________________________

6. Additional information.

Yes No

(Mark each answer.)

○ ○

a. Have you ever been removed from

or asked to leave a leadership

 

position in an organization due to

 

allegations regarding your personal

 

conduct or behavior? Explain:

 

I hereby certify that:

 

 

 

 

 

 

 

 

 

 

1.

I have read and affirm that I accept the Declaration of Religious Principle. I agree to comply with the rules and regulations of

INITIALS

 

 

 

 

 

the BSA and the local council, including the Scouter Code of Conduct.

REQUIRED

 

 

 

 

 

 

_________

Signature of applicant

 

Date

2.

I affirm that the information contained in this application is true and accurate to the best of my knowledge and belief.

INITIALS

YPT completion certificate attached

Background Check Authorization form attached

 

 

REQUIRED

 

 

_________

To be completed by unit

Careful review of the information provided on this application is a significant step in Scouting’s efforts to protect its youth members and deliver a quality program.

APPROVALS FOR UNIT ADULTS: I have reviewed this application and the responses to any questions answered “Yes,” and

 

APPROVAL FOR COUNCIL AND DISTRICT ADULTS: I have reviewed this application and have made any follow-up inquiries

have made any follow-up inquiries necessary to be satisfied that the applicant possesses the moral, educational, and

 

necessary to be satisfied that the applicant possesses the moral, educational, and emotional qualities to be an adult leader

emotional qualities to be an adult leader in the BSA.

 

in the BSA.

 

 

 

 

 

 

b. Do you use illegal drugs or abuse

○ ○

alcohol? Explain:

 

c. Have you ever been arrested for a

○ ○

criminal offense (other than minor

 

traffic violations)? Explain:

 

d. Has your driver’s license ever been

○ ○

suspended or revoked? Explain:

 

Signature of chartered organization head or representative

 

 

 

Unit

Pack

Troop

New leader

Position change

type:

Crew

Ship

Former leader

Participant

 

 

 

 

 

 

 

District name

 

 

 

Unit

 

 

 

 

 

OR

 

 

 

 

 

No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Registration $

 

 

 

 

 

Boys’ Life

$

 

 

fee

 

 

 

 

 

 

 

fee

 

 

 

Date

Signature of Scout executive or designee

Date

If applicant has an unexpired membership certificate, registration may be accomplished at no charge by transferring the registration or multiple registering.

Transfer application

 

 

 

 

 

 

Enter membership number

 

 

 

Multiple application

 

from unexpired certificate:

 

 

 

 

Unit

Pack

Troop

 

 

 

Council No.:

 

 

Unit No. or

 

 

 

 

 

type:

Crew

Ship

District name:

 

 

 

 

 

 

 

 

 

 

 

 

 

PAID: ○ Cash

○ Check No. _________

○ Credit card

e.

Have you ever been investigated for,

○ ○

 

accused of, or charged with abuse or

 

 

neglect of a minor child? Explain:

 

f.

Are you aware of any reason

○ ○

not listed above that may call into question your suitability to supervise, guide, care for, and lead young people?

524-501

Tear off the following pages and provide to applicant separately.

BACKGROUND CHECK

DISCLOSURE

A consumer report is a background check in which information (which may include, but is not limited to, criminal background, driving background, character, general reputation, personal characteristics, and mode of living) about you is gathered and communicated by a consumer reporting agency (“CRA”) to Boy Scouts of America and/or its subsidiaries, affiliates, other related entities, and/or successors (the “Company”).

Company may obtain a consumer report on you to be used for employment purposes (in your case, this means for the purpose of evaluating you as a new or existing volunteer).

CALIFORNIA

STATE LAW DISCLOSURES

(Non-Credit)

Under California law, an “investigative consumer report” is a consumer report in which information on a consumer’s character, general reputation, personal characteristics, or mode of living is obtained through any means. Boy Scouts of America and/or its subsidiaries, affiliates, other related entities, and/or successors (the “Company”) may obtain an investigative consumer report (which may include information described above) from an investigative consumer reporting agency (“ICRA”) on you in connection with your status as a volunteer (i.e., for employment purposes under California law). The nature and scope of this investigation includes your character, general reputation, personal characteristics, or mode of living information, including criminal history and driving record.

The ICRA preparing the investigative consumer report and conducting the investigation will be First Advantage, P.O. Box 105292, Atlanta, GA 30348, 800-845-6004. Information regarding First Advantage’s privacy practices can be found at https://fadv.com/privacy-policy/.

Under California Civil Code section 1786.22, you are entitled to a visual inspection of files maintained on you by an ICRA, as follows:

(1)In person, if you appear in person and furnish proper identification, during normal business hours and on reasonable notice. A copy of your file shall also be available to you for a fee not to exceed the actual costs of duplication services provided;

(2)By certified mail, if you make a written request, with proper identification, for copies to be sent to a specified addressee. An ICRA complying with requests for certified mailings under California Civil Code section 1786.22 shall not be liable for disclosures to third parties caused by mishandling of mail after such mailings leave the ICRA;

(3)A summary of all information contained in your files and required to be provided by California Civil Code section 1786.10 shall be provided to you by telephone, if you have made a written request, with proper identification for telephone disclosure, and the toll charges, if any, for the telephone call are prepaid by you or charged directly to you.

“Proper Identification,” as used above, means information generally deemed sufficient to identify you, which includes documents such as a valid driver’s license, social security account number, military identification card, and credit cards. Only if you cannot identify yourself with such information may the ICRA require additional information concerning your employment and personal or family history in order to verify your identity.

The ICRA will provide trained personnel to explain any information furnished to you pursuant to California Civil Code section 1786.10 and will provide a written explanation of any coded information contained in files maintained on you. This written explanation will be provided whenever a file is provided to you for visual inspection under California Civil Code section 1786.22.

You may be accompanied by one other person of your choosing, who must furnish reasonable identification. An ICRA may require you to furnish a written statement granting permission to the ICRA to discuss your file in such person’s presence.

ADDITIONAL DISCLOSURES & BACKGROUND CHECK AUTHORIZATION

Additional Disclosures

The state disclosures below are included because state law requires them to be provided in writing. Some of the below rights, notices, or information also may apply to individuals from, applying to, or volunteering in states not listed below. There may be additional requirements, options, or provisions applicable to you and you may have additional rights under applicable law that are not required to be disclosed to you in writing.

Minnesota: You have the right to request a complete and accurate disclosure of the nature and scope of any consumer report from First Advantage, P.O. Box 105292, Atlanta, GA 30348, 800-845-6004.

New York: Boy Scouts of America and/or its subsidiaries, affiliates, other related entities, and/or successors (the “Company”) may request or utilize subsequent consumer reports (other than investigative consumer reports) on you throughout your volunteer relationship with Company. Upon request, you will be informed whether or not a consumer report was requested, and if such report was requested, informed of the name and address of the CRA that furnished the report. Your written request should be made to Company at Boy Scouts of America, Membership Standards Team S201, 1325 West Walnut Hill Lane, P.O. Box 152079, Irving Texas 75015-2079. You may also contact the Company by email at MembershipStandards@scouting.org.

AUTHORIZATION

(Please print)

Name: First ____________________ Middle _______________Last ________________________ Suffix _________

List any other names used (nickname, maiden/married last names:):_________________________________________

i

Date of Birth: _______________________________ Unit Type and Number: _______________________________

To the extent permitted by applicable law, I hereby consent to and authorize the Boy Scouts of America and/or its subsidiaries, affiliates, other related entities, and/or successors (the “Company”) to procure consumer report(s) (as defined by federal law) and/or investigative consumer report(s) (as defined by applicable California state law), which in my case means criminal background check(s)/driving record(s), on my background from a consumer reporting agency (“CRA”) or from an investigative consumer reporting agency (“ICRA”), as described in the Background Check Disclosure and the California State Law Disclosures (Non-Credit) (each of which I have received separately from the Company), as well as these Additional Disclosures & Background Check Authorization. This authorization applies only to criminal checks/driving records and does not allow the Company to obtain credit checks. I have reviewed and understand the information, statements, and notices in the Background Check Disclosure and the California State Law Disclosures (Non-Credit), as well as these Additional Disclosures & Background Check Authorization. My authorization remains valid throughout my volunteer relationship with the Company, such that, to the extent permitted by applicable law, I agree Company can procure additional consumer report(s), which in my case means criminal background check(s)/driving record(s), during my volunteer relationship without providing additional disclosures or obtaining additional authorizations. Except as otherwise prohibited by applicable law, I consent to and authorize the Company to share this information with Company’s local councils and/or chartered organizations for business reasons (e.g., to place me in certain positions, work sites, etc.). I understand that, if I am selected for a volunteer position, a consumer report will have been conducted on me.

For California, Minnesota, or Oklahoma individuals: If you would like to receive from the CRA, the ICRA, or the Company (as applicable) a copy of the report that Company may procure, please check this box.

Signature _______________________________________ Date ________________________________________

02/2020

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