CONFIDENTIAL
Background Check Authorization
Print Name: _____________________________________________________________
(First) (Middle) (Last)
Current Address Since: ________________________________________________________
(Mo/Yr) (Street) (City) (Zip/State)
Previous Address From: _________________________________________________________
(Mo/Yr) (Street) (City) (Zip/State)
Social Security Number: ___________________________ DOB: ______________________
Telephone Number: __________________________________________________
Driver’s License Number/State: _____________________________________
References: _____________________________________________
The information contained in this application is correct to the best of my knowledge.
I_________________________________________ (NAME) hereby authorize [NAME OF COMPANY] and its designated agents and representatives to conduct a comprehensive review of my background causing a consumer report and/or an investigative consumer report to be generated for employment. I understand that the scope of the consumer report/ investigative consumer report may include, but is not limited to the following areas:
- verification of social security number;
- credit reports,
- current and previous residences;
- employment history,
- education background,
- character references;
- drug testing,
- civil and criminal history records from any criminal justice agency in any or all federal, state, county jurisdictions;
- Driving records, birth records, and any other public records.
I further authorize any individual, company, firm, corporation, or public agency to divulge any and all information, verbal or written, pertaining to me, to or its agents. I further authorize the complete release of any records or data pertaining to me which the individual, company, firm, corporation, or public agency may have, to include information or data received from other sources and its designated agents and representatives shall maintain all information received from this authorization in a confidential manner in order to protect the applicants personal information, including, but not limited to, addresses, social security numbers, and dates of birth.
Signature: ______________________________________ Date: ______________
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