DIOCESE OF MANCHESTER

Background Screening Authorization

Clerics and Persons in Ecclesiastical Studies

This Authorization will be maintained in the personnel file of each cleric at the diocesan central administration office.
Such records are treated in a confidential manner and disclosed only to the personnel themselves, the Bishop of
Manchester, the Office for Ministerial Conduct, and those with a legitimate need to know in accordance with church
and civil law. Please complete in full and print your answers.

Name
First Middle Last

List any other names you have been known by, including religious name:

Date of Birth* Phone Email address

* Date of birth is requested for identification purposes only

Address
Street Unit/Apt. #

City/Town State Zip Code

Have you resided in any states other than NH during the past 5 years? (circle) Yes No

If yes, list all states:

Have you ever been convicted of a crime (including driving while impaired or its equivalent, but excluding minor
motor vehicle offenses) that has not been annulled by a court of law? Yes No

Have you ever been investigated by the New Hampshire Division for Children, Youth and Families (“DCYF”) or
another child protection agency? Yes No

Have you ever committed, been accused of, or been convicted of physical or sexual abuse or neglect of a minor (person
under age 18) or a vulnerable adult? Yes No

Have you ever been subject to any court order involving an allegation of sexual, physical, or verbal abuse of a minor
or a vulnerable adult? Yes No

(If you answered yes to any of the above questions, please provide an explanation on a separate sheet of paper and
attach it to this form).

Please sign below to indicate you have read and understand the following statements:

I certify that the above information is true and complete to the best of my knowledge and belief. I understand that any
statement I have furnished which is shown to be false when made will be cause for appropriate canonical penalties.

I authorize the release of my criminal conviction record information to the Bishop of Manchester and his delegates
in the Office for Ministerial Conduct. In addition, I release any person, firm, corporation, or government agency
from any previous agreement, verbal or written, which would prohibit the release of information pertinent to this
background check. I understand that it is my obligation to notify the Bishop or Vicar for Clergy within 14 days if I
am arrested or convicted of a crime after signing this form.

I understand, in accordance with church law, that no person who admits or is found to have sexually abused a child
can exercise any ministry in the Church and that the Diocese of Manchester has a policy regarding the thorough
investigation of all reports of child sexual abuse by any church personnel. I further understand that the Diocese of
Manchester cooperates fully with the civil authorities in their investigation of all reports of a crime, including the
sexual abuse of a minor.

Signature: ______________________________________________ Date: ______________________

Version 3.1
January 2021