Application Background Release Sample


Posted on May 4, 2012 by admin | in Background Check

APPLICANT BACKGROUND CHECK RELEASE



TO BE COMPLETED BY APPLICANT
Please Use an Ink Pen or Type Using Form Fields. Use “UPPER CASE” Letters. One Letter Per Block.

Last Name                                                    
First Name                                                    
Middle Name                                                    
Current Address                                             Apt      
City                                   State     Zip          
Social Security Number                       XXX XX XXXX List other SS#s used in “Other” Box
Date of Birth                 MM/DD/YY
Driver’s License No                                 State     Is Name on DL Same? Yes | No
Other Names Used (A.K.A.’s)                                                    
Other States/Counties
I Have Lived/Worked
or was a Student 		  STATE COUNTY ZIP CODE FROM (YR) TO (YR)   STATE COUNTY ZIP CODE FROM (YR) TO (YR)
1                         3                        
2                         4                        


I authorize                                to procure reports in connection with my application for employment,
reassignment or promotion. These reports may include, but are not limited to the following types of consumer and investigative reports: credit history,
work experience, bankruptcy records, workers compensation, previous employer interviews, education verification, driving records, criminal records,
general reputation, from private, local, state and/or federal agencies which maintain such records. I authorize any party or agency contacted
by                            , or its AGENT(s) to furnish the aforementioned information and
I release                             from any claims that may arise. I have the right to make a
request to            , to request the nature and substance of information in its files
and recipients of any reports, which                          has previously furnished within the two-year period.
I hereby authorize the procurement of any and all consumer and investigative reports. This authorization shall remain on file and shall
serve as on-going authorization for you to procure consumer reports at any time during my employment period.
I understand if information contained on this authorization contains misleading, erroneous or deceptive information, I will be eliminated from further consideration.

________________________________________________________
APPLICANT SIGNATURE/ DATE

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