Directions:

1. Payment (information at bottom of form)
2. Fill out form
3. Not valid without receipt of payment
4.  After both are received you will hear from a GLR representative

Those desiring to register with the Great Lakes Region in the ministerial development journey or credentialing, complete the following information authorizing the Great Lakes Region of The Wesleyan Church to conduct a Criminal Background and Credit Check on your behalf.

All information will remain confidential and will only be used by officials of the Region and General Church who are authorized to review confidential Ministerial records. Using the link below to pay for the Background Check. 

If you would prefer not to submit this information via the internet, you may complete the form and prior to submitting it, save it as a pdf to your computer. After the document is saved, leave the page without clicking the "submit" button. The information may then be printed and mailed to the Regional Office. Great Lakes Region of The Wesleyan Church, 3040 Ivanrest Ave SW, Grandville, MI 49418.

Question Title

* 1. First Name

Question Title

* 2. Middle Name 

Question Title

* 3. Last Name

Question Title

* 4. Spouses full name(if applicable)

Question Title

* 5. Reason for Requesting Background and Credit Check

Question Title

* 6. Street Address

Question Title

* 7. City

Question Title

* 8. State

Question Title

* 9. Zip Code

Question Title

* 10. Phone number

Question Title

* 11. Email address

Question Title

* 12. Social Security Number

Question Title

* 13. Date of Birth

Please provide month/date/year, 00-00-0000

Question Title

* 14. Driver's License Number

Question Title

* 15. State issuing License:

Question Title

* 16. Alias/Maiden name

If you are known by another name or alias, please provide names below.

Question Title

* 17. Information

Please describe any information that may be in your Criminal or Credit Background checks that would be important for the Regional team to know as they review the information.

Permission to Conduct Background Checks

Please indicate your approval for conducting the criminal background check , credit check and freedom to share findings with Region and Church Leaders by checking the appropriate box below and typing your name as a form of electronic signature. Your personal information as well as the information provided in the reports will be kept confidential. You may receive copies of the information received by requesting this information through the Regional Office. You will be notified of any issues arising from the information received and will have the opportunity to discuss how this may affect your relationship with the Region.

Question Title

* 18. Granting Permission

I agree to allow the Great Lakes Region of The Wesleyan Church to conduct a criminal background and credit check on my behalf.

Question Title

* 19. Payment: 

The cost of completing a Criminal Background and Credit Check is $30. Payment should be made through Paypal at the link below.  Important:  Your enrollment form is not valid without payment. Please be sure to select the "Done" link  at the bottom of this page in order to submit your information.

Please use our PayPal link to Pay Now  and indicate below the email used for payment.

Question Title

* 20. Electronic signature

In typing my name, I am providing an electronic signature granting approval for the above-mentioned background and credit check.

T