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Employee Time Sheets

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EMPLOYEE TIME SHEET


___________________________
Name
___________________________
Month / Year

CODES:

V =Vacation, L =Late, E =Left early, O =Other, I/S =Illness absence, D =Discretionary Day

Enter Date
(M/D/Yr)
Day of week
(M T W T F S Su)
Times/Total Code Parent Initials
         
         
         
         
         
         
         
         
         
         
         
         
         
         
         

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Employee Emergency Contact Information

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EMPLOYEE EMERGENCY INFORMATION FORM


Personal Information FOR EMPLOYEE TO FILL OUT SHOULD THERE BE AN EMERGENCY
Contact First name  
Middle name  
Last name  
Place of birth (country/region)  
Home address  
 
Home phone  
Cellular phone  
Birthday (MM/DD/YYYY)  
Medical Information
Doctor’s name  
Address  
 
Phone number  
Blood type  
Medical conditions  
Allergies  
Current medications  
Additional Emergency Information
Emergency contact’s name  
Relationship  
Address  
 
Phone number(s)  

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How to Access Driving, Education/Reference and Military Information

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NannyClearinghouse.com


Driving Records:

When checking an applicant’s driving record for employment purposes compliance with federal and state laws is paramount.
The major law governing access and privacy is the federal Drivers Protection Privacy Act (DPPA).
Childcare companies that do a fair amount of annual volume may want to set up an account with a DMV reseller or contact the DMV directly to set up an account.
There a several state and legal forms a business must sign in order to have access to this data.
Some states require annual certification, the posting of a bond and others place restrictions in order to conform to state and federal laws.
For families who do not qualify for a reseller account, you can ask your applicants’ to provide a copy of their DMV record with their background check release.
Most will allow online record printouts with a small fee.
Use caution with any applicant supplied record it should be used as a last resort as it is always better to go to a third party vendor.

To check the status of a DL for free check out:

Florida – https://services.flhsmv.gov/DLCheck/

Idaho – https://www.accessidaho.org/secure/itd/reinstatement/index.html

Kansas – https://www.kdor.org/DLStatus/login.aspx?ReturnUrl=%2fdlstatus%2fsecure%2fdefault.aspx

Massachusetts – https://secure.rmv.state.ma.us/LicInquiry/intro.aspx

Minnesota – https://dutchelm.dps.state.mn.us/dvsinfo/mainframepublic.asp

Nebraska – https://www.nebraska.gov/dmv/reinstatements/client.cgi

North Dakota – https://secure.apps.state.nd.us/dot/dlts/dlos/requeststatus.htm

Ohio – www.ohiobmv.com/abstract.stm

South Carolina – https://www.scdmvonline.com/DMVpublic/trans/DRecPoints.aspx

Washington – https://fortress.wa.gov/dol/dolprod/dsdDriverStatusDisplay/

West Virginia – http://www.transportation.wv.gov/dmv/Pages/dlverify.aspx

Wisconsin – https://trust.dot.state.wi.us/occsin/occsinservlet?whoami=statusp1

Reference Checks:

Many large and Fortune 500 companies are only providing references via an automated database.
For past employment verifications the Work Number is a source for over 5000 employers (see list on their site).

Reference Verifications

The Work Number www.theworknumber.com

Approximately 2000 employers use this service for their previous employment verifications.

Military Verifications

From time to time you will have an applicant with a military background. The standard way to verify military records is to ask an applicant for a copy of their DD-214.
This is the short name for “discharge papers” Employers should ask for “copy #4” which has the most information about the applicant’s military history.
If the applicant doesn’t have a copy you can request copy #1 which has the least amount of information. Have the applicant sign Form 180 and send it to the NPRC in St.
Louis MO. To obtain the form go to http://www.archives.gov/research/order/standard-form-180.pdf

Workers Compensation Records

Use caution with these records as they are usually ordered after a conditional offer of employment has been extended.
Under Americans with Disabilities Act an employer may not inquire about an applicant’s medical condition until a conditional offer is made.
To order you must contact the state Workers’ Comp Division and follow their procedures. Availability depends on the state; some require a specific form with a fee.
Some states take several weeks to return information while others prohibit the inquiry. States that do not allow access:

All states except: Alabama, Georgia, Indiana, Maine, Michigan, Montana, Nevada, New York, North Carolina, Oregon, Rhode Island, Texas, Washington, West Virginia, and Wisconsin.

For further information see the below link:

http://www.dol.gov/owcp/dfec/regs/compliance/wc.htm

Civil Court Records

Another screening service option is civil records. Unlike criminal records civil records usually enter the court system as a law suit about money.
People can be found not guilty in a criminal case and be sued civilly and be found guilty.
This is primarily because the burden of proof is much different in a civil case than a criminal case.
The burden of proof is much less (preponderance of evidence vs. beyond a reasonable doubt).
Obtaining these records are similar to criminal record with a few exceptions.
Some identifiers in civil suits are not included in the court record which complicates matters if you have an applicant with a common name.
To confirm if your applicant is the actual defendant you must look for clues in the civil file (addresses/ employers/ specific unique references) in the civil case file.
This requires the pulling of the entire file at the courthouse where the case was filed.
Most online searches only provide the docket sheet which is a general entry on the case and not the specific file with motions and specific decisions.
This is why it is important to have record retrievers or a company that regularly accesses these records physically at the courthouse.
Some common civil suits are for:

  • Breach of Contract
  • Unlawful Detainer (eviction)
  • Malpractice
  • Fraud

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Documentation of Training Form

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DOCUMENTATION


Please attach any documentation of training or requested ID.

Including:      
US State Drivers License Yes College Transcripts Yes
International Driving Permit Yes High School Diploma Yes
International Drivers License Yes College Degree Yes
Insurance Card (driving) Yes Continuing Education Yes
US State ID Card Yes Au Pair Training Yes
Social Security Card Yes Governess Training Yes
Passport Yes First Aid Yes
Birth Certificate Yes LPN Yes
Green Card Yes    
ITIN # Yes    
Military ID Yes    
Training Certification (s) Yes    
CPR Certification Yes    
Lifesaving Yes    
Defensive Driving Yes    
Early Childhood Development Yes    
Continuing Education/Certificate Yes    

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Childcare Employment Contract

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CHILDCARE EMPLOYMENT CONTRACT/JOB DESCRIPTION


Date of Issue:         -2012

BETWEEN

(1) (“the Employer”) _______________________________________________________

(2) (“the Nanny”) _________________________________________________________

Our agreement with you:

IT IS AGREED that the Employer will employ the Nanny on the following terms and conditions:

1. Terms of Employment

1.1 The Nanny is employed to work at the Employer’s home at or such other place(s) as the Employer may reasonably require from time to time.
The employment commenced on and shall not be continuous with any previous period of employment.
Employment is considered “at will”. Employer and Employee may terminate the contract at any time, with or without cause, however:

  1. If the employee is terminated without cause, the employer is obligated to provide _______ weeks’ severance pay.
  2. If the employee decides to leave the position with cause, the employee will provide at least ______ week(s) notice or, if requested, remain until a replacement Nanny is found.
    No severance pay is required if employer wishes to terminate before the ______ week(s) notice period.

1.2 The Nanny’s duties shall be: (To provide quality childcare, overall plan activities to encourage social, physical,
emotional and intellectual development of the children (check all that apply)

(a) ROOMS: _____ “picked up”; ____ bed made daily. (k) TUTORING (specify): ______________________
(b) EMPLOYER’S BEDROOM _____________ (l) ARRANGING DOCTOR/DENTAL VISITS
(c) MEAL PLANNING _______________________ (m) DRIVING: _____ children’s activities
(d) DUSTING _______________________________ (n) OTHER: ____________________________
(e) CLEANING OF BATHROOMS ____________ (o) __________________________________
(f) LAUNDRY _______________________________ (p) __________________________________
(g) REMOVING TRASH; ________________________ (q) __________________________________
(i) DISHES: ___ breakfast; ____ lunch; _____ dinner (s) __________________________
(j) COOKING: ___ breakfast;____ lunch; _____ dinner

1.3 The Nanny shall work the following days:

1.4 Normal working hours shall be agreed by the Employer and Nanny in advance, but shall generally be:

1.5 The Nanny shall be entitled to a rest period of not less than ____ consecutive hours between the end of her normal
working hours on one day and the commencement of her normal working hours on the following day.
It shall be the responsibility of the Nanny to ensure that she takes such a rest period.

1. Terms of Employment (continued)

1.6 Unless prevented by illness or injury the Nanny:

(a) Shall devote the whole of her time, attention and ability, both during normal working hours and during such other reasonable additional hours
as may be agreed between the Employer and Nanny, for the performance of her duties for the employer, and

(b) Follow all lawful instructions of the Employer;

(c) Not perform any paid or unpaid work for any third party without the prior written consent of the Employer.

2. Compensation

2.1 The Nanny’s gross salary will be $______ per (week/month). The salary shall be reviewed (once/twice) a year on___________________ but any increase
in salary shall be at the total discretion of the Employer.

2.2 The salary shall be payable_______________________________(date) by a check or a direct debit payment direct to the Nanny’s bank, as agreed by the parties.
The Employer shall ensure that the Nanny is given a paycheck stub on the date of payment detailing gross payment, deductions and net payment.

2.3 The Nanny shall receive the following benefits:

(a) Accommodation

(b) Meals

(c) Use of car

The Employer (does/does not) provide the use of a car.

(d) Pension

The Employer (does/does not) provide pension contributions.

(e) Health Insurance

The Employer does/does not provide private health insurance.

2.4 The Nanny shall be reimbursed by the Employer for all reasonable expenses incurred by her in the performance of her
duties under this contract, provided that the expenses are incurred with the approval of the Employer and provided the Nanny
produces such evidence of expenditure as the Employer may reasonably require.

2.5 The Nanny agrees that the employer shall be entitled to deduct from any amount payable to the Nanny under this contract:

(a) Any deductions required by law (income tax), and

(b) Any monies owed by her to the Employer by way of reimbursement.

3. Holidays

3.1 The holiday year will start on ____________________

3.2 In each holiday year the Nanny’s holiday entitlement is___ weeks (in addition to/including the usual public and bank holidays/The Nanny
shall not be entitled to paid time off for public and bank holidays except with the express agreement of the Employer.).

3.3 Holiday pay will be made at the Nanny’s normal rate of remuneration. One day’s accrued holiday pay is equivalent to 1/260th of the Nanny’s salary.

3.4 The Nanny will not be allowed to carry holiday pay forward from one leave year to the next or (subject to clause 3.7)
receive payment in lieu of any untaken holiday entitlement and the Nanny shall ensure that she takes such entitlement within the holiday year.

3.5 The Nanny shall give the Employer not less than 2 weeks notice of an intention to take holiday. If the holiday period requested is
not convenient to the Employer, the Employer shall agree an alternative period, which is convenient to both parties. The Nanny will not be
allowed to take more than 10 working days holiday at any one time.

3.6 There is no entitlement to take unpaid holidays. (Please note this clause must not be used if it effectively
deprives the Nanny of taking her holiday in the holiday year. Where the Nanny is working out any notice following
either party giving notice to terminate this contract, the Nanny may be required to take any unused holiday during that notice period.

3.7 On the termination of her employment, the Nanny will be paid any holiday entitlement accrued but not taken. If the Nanny has taken more days’
holiday than her accrued entitlement, the Employer will make the appropriate deduction from the Nanny’s final salary payment (calculated in accordance with Clause 4.3).

3.8 If the Nanny is required to work on a bank or other public holiday, the Nanny will be given a day off in lieu on a date to be agreed by the Employer.

4. Sick Pay/Illness

4.1 If the Nanny is unable to attend work due to sickness or injury she shall (insofar as she is able)
promptly notify the Employer either in person or by telephone (as appropriate) on the first day of absence
and provide the Employer with such evidence of her sickness or injury and the cause of it as the Employer may from time to time reasonably require.

4.2 The Employer shall be entitled to require the Nanny to undergo examinations by a medical practitioner appointed by the Employer,
and the Nanny shall sign the necessary consent form to authorize the medical practitioner to disclose to the Employer the results of
the examination and discuss with the employer any matters arising from the examination which might impair the Nanny’s ability to properly discharge her duties).

5. Confidentiality

5.1 The Nanny shall not during her employment with the Employer, or at any time thereafter (otherwise than in the proper course
of her duties or as is required by law) without the prior written approval of the Employer divulge or disclose ANY information which,
by reason of its character or the circumstances or manner of its disclosure, is evidently confidential to the Employer.

6. Termination

6.1 If either party wishes to terminate this contract, the notice to be given shall be as follows:

During the first two weeks of employment is defined as the (“the Probationary Period”) which means ___

b) Thereafter, not less than ___week(s) notice in writing.

6.2 The Nanny’s employment under this contract may be terminated by the Employer at any time immediately and without any notice or payment in lieu of notice if the Nanny:

(a) Is guilty of gross misconduct or serious and persistent breaches of the terms of this contract, or

(b) Is convicted of any criminal offence involving dishonesty, violence, causing death or personal injury, or damaging property.

6.3 Misconduct which may be deemed gross misconduct includes but is not limited to theft, drunkenness, use of illegal drugs,
child abuse and inappropriate violent behavior (be it verbal or physical).

7. Disciplinary & Capability Procedure

7.1 Reasons which might give rise to the need for measures under the Disciplinary & Capability Procedure include the following:

(a) Causing a disruptive influence in the household

(b) Job incompetence

(c) Unsatisfactory standard of dress or appearance

(d) Conduct inside or outside Normal Working House prejudicial to the interests or
reputation of the employer.

(e) Unreliability in time keeping or attendance

(f) Failure to comply with instructions and procedures

(g) Loss of driving license

(h) Breach of confidentiality

7.2 In the event of the Employer needing to take disciplinary action the procedure shall be:

1st Incident:            Verbal Warning

2nd Incident:           Written Warning

3rd Incident:          Dismissal

8. Grievance Procedure

If the Nanny has any reasonable grievance relating to her employment the matter should be raised with the Employer either in person or in writing as the Nanny deems appropriate.
The Employer and the Nanny agree to take all such reasonable steps as necessary to resolve such grievances.

9. General

9.1 This contract shall be construed in accordance with and governed by the laws of __________(state).

9.2 Any reference in this contract to any statutory provision shall be deemed to include a reference to any statutory modification or re-enactment
of it and shall also include reference to all statutory instruments and orders made pursuant to any such statutory provision.

9.3 Words in the singular shall include the plural and vice versa, and references to any gender shall include the other and a reference
to a person shall include a reference to any Company as well as any legal or natural person.

9.4 Employment is at will and can be terminated at anytime by employer with or without cause.

__________________________________
SIGNED by the Employer:
_____________________
DATED
__________________________________
SIGNED by the Nanny:
_____________________
DATED

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Childcare Employment Application

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PLEASE USE AN INK
PEN AND PRINT ALL
FIELDS EXCEPT
SIGNATURE

CHILDCARE EMPLOYMENT APPLICATION FORM

Date received:

By:



PLEASE COMPLETE PAGES 6-10 DATE ___________________________

Name ___________________________________________________
Last First Middle Other Names  
Present address ___________________________________________________
Number Street City State Zip
How long at current address:_________________________________          Social Security No. ______-______-______

ITIN No. _________________ (registered aliens)

Telephone (          ) Cell Phone (          ) Other Telephone (          )

Are you under age 18 _____YES _____NO, if “YES”, Do have proof of your eligibility? _____YES _____N0

Are you currently authorized to work in the United States? ____YES _____NO

Position applied for (1) _____________________ Days/hours available to work

How many hours can you work weekly? ______________________

Employment desired
FULL-TIME ONLY

PART-TIME ONLY

LIVE-IN

LIVE-OUT

When are you available to start work?_________________ Other Information: _____________________

DO YOU HAVE A DRIVER’S LICENSE?

Yes


No

What is your means of transportation to work? Type Year

Driver’s license
number ____________________________ State of issue _______

Operator


Commercial (CDL)

Expiration date _____________________

Have you had any accidents during the past three years? How many? _______________

Have you had any moving violations during the past three years? How Many? __________________

If you are driving your vehicle with children, is it insured?

Yes


No

Name of Company

Policy No. and Limits

Ability to drive a stick shift?

Yes


No


Please list two references other than relatives.

Name ____________________ Name ____________________
Position ____________________ Position ____________________
Company ____________________ Company ____________________
Address ____________________ Address ____________________
____________________ ____________________
Telephone ____________________ Telephone ____________________


MILITARY

HAVE YOU EVER BEEN IN THE ARMED FORCES?
Yes

No
ARE YOU NOW A MEMBER OF THE NATIONAL GUARD?
Yes

No
Specialty___________________________ Date Entered __________________________ Discharge Date ______________________

Work Experience
Please list your work experience for the past seven years beginning with your most recent job held. If you were self-employed, give firm name. Attach additional sheets if necessary.


Name of employer Address Name of last supervisor Employment Dates Pay or salary
City, State, Zip Code Landline Phone number (no cell) From:
To:
Start
Final
Your Last job title
Reason for leaving (be specific)
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.

Name of employer Address Name of last supervisor Employment Dates Pay or salary
City, State, Zip Code Landline Phone number (no cell) From:
To:
Start
Final
Your Last job title
Reason for leaving (be specific)
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.
Name of employer Address Name of last supervisor Employment Dates Pay or salary
City, State, Zip Code Landline Phone number (no cell) From:
To:
Start
Final
Your Last job title
Reason for leaving (be specific)
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.
Name of employer Address Name of last supervisor Employment Dates Pay or salary
City, State, Zip Code Landline Phone number (no cell) From:
To:
Start
Final
Your Last job title
Reason for leaving (be specific)
List the jobs you held, duties performed, skills used or learned, advancements or promotions while you worked at this company.

TYPE OF SCHOOL

NAME OF SCHOOL

LOCATION

(Complete mailing address)

NUMBER OF YEARS COMPLETED

MAJOR & DEGREE

High School        
         
College        
         
Bus. or Trade School        
         
Professional School        
         

May we contact your present employer?
Yes

No
Did you complete this form yourself?
Yes

No
If NOT, who did? ___________________
If there is any additional information please attach to the following form.

(Employer)______________________is an equal employment opportunity employer. We adhere to a policy of making employment decisions without regard to race, color,
religion, gender, sexual orientation, national origin, citizenship, age or disability.
We assure you that your opportunity for employment with __________________________ depends solely on qualifications.
I understand if information contained in this application contains misleading, erroneous or deceptive information,
I will be eliminated from further consideration. I have never been convicted of abuse, neglect or been the subject of a substantiated claim of abuse or neglect regarding children.
I further attest that while caring for children I will not consume or take any alcohol or narcotics or any other substance that may impair my ability to care for children.

___________________________
Signature of Applicant
___________________________
Date


ADDITIONAL INFORMATION SHEET FROM APPLICATION:

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Checklist on Sources of Background Information

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SOURCES OF INFORMATION CHECKLIST


Applicant::

Background Check Start Date: ___ / ___ / ___

Background Check Complete Date: ___ / ___ / ___

Completed
Pending N/A Unk N/N NOTES
APPLICANT NAME            
APPLICANT ALIASES            
NANNY CLEARINGHOUSE™ DATABASE            
SOCIAL SECURITY VERIFICATION            
DATE/STATE SOCIAL SECURITY ISSUE (1)            
PREVIOUS ADDRESSES REPORTED            
A.K.A.’S REPORTED FROM SS TRACE            
DEATH FILE W/SOCIAL SECURITY ADMIN.            
(1) FEDERAL DISTRICT CRIMINAL COURT            
NATIONWIDE SEX OFFENDER REGISTRY            
(1) COUNTY DISTRICT CRIMINAL COURT            
(2) COUNTY DISTRICT CRIMINAL COURTS            
NATIONAL SECURITY WATCHLISTS            
(3) COUNTY DISTRICT CRIMINAL COURTS            
(1) REFERENCE VERIFICATION            
(4) COUNTY DISTRICT CRIMINAL COURTS            
(1) FORMER EMPLOYER VERIFICATION            
STATEWIDE CRIMINAL REPOSITORY*            
LIMITED NATIONWIDE CRIMINAL DATABASE            
(5) METRO COUNTY CRIMINAL COURTS            
STATE DRIVING RECORD *            
DEPARTMENT OF CORRECTIONS            
COUNTY CIVIL COURT RECORDS            
STATE WORKERS COMPENSATION RECORDS            
NEWSPAPER SEARCHES            
SOCIAL MEDIA            
             
             
             
             

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Do it Yourself Applicant Reference Verification

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APPLICANT REFERENCE VERIFICATION


___________________ has applied for a childcare position and has listed you and/or your company as a former employer or reference.
As part of our pre-employment procedure, your answers to the following questions would be appreciated.

Position Held: ____________________________________ From/To: ______________________

Starting/Ending Salary: ___________________________________________________________

Reason for Leaving: ______________________________________________________________

SECTION ONE

Applicant Name: ___________________________________ Position: Childcare

Social Security #: N/A________________________________ DOB ________________________

Reference Name: _____________________________________Phone: ______________________

Company Name: ______________________________________ Position/Title: _______________

SECTION TWO

What were the overall responsibilities of this individual?

How would you describe or rate this individual’s performance?

Would you recommend him/her for this position? If no, why not?

Would this individual be eligible for rehire? If no, why not?

On average, how many times did the applicant miss work or come in late? Does he/she have any personal problems or bad habits that interfered with his/her job performance?

Whom did the applicant work for prior to joining your company? When hired were his/her references checked? What did the references have to say?

Who else knows the applicant?

Name: Title: Phone:
Name: Title: Phone:
Name: Title: Phone:

Overall Performance (circle):

Exceptional

Very Good

Satisfactory

Some reservation

Unsatisfactory

Comments

Thank you for your assistance in this matter. The reference check form may be mailed to our address or faxed to our fax number.

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Applicant Medical Information

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MEDICAL INFORMATION


How would you rate your general health?

  • Excellent
  • Fair
  • Good
  • Poor

When was your most recent medical check up?____________________________

Have you ever consulted a physician or been diagnosed for any of the following:

  Yes NO If Yes, Please Explain
1.Prescribed Medicine      
2. Diabetic      
3. Contagious Skin rashes or other skin problems      
4. Frequent illness/viruses      
5. Anemia, mononucleosis or hepatitis      
6. Eating disorders      
7. Severe back or neck pain      
8. Nervous disorders or other mental disorders      
9. Venereal Diseases or A.I.D.S.      
10. Alcoholism or drug dependency      
11. Fainting spells or dizziness      
12. Allergic to certain substances      
13. Smoking      
14.Allegies      
15. Difficulties Seeing/Hearing      
16.Chicken Pox      
17. Health Insurance/company      
18. Eating Disorder      
19. Diagnosed with any illness      
20. Any disabilities which that we should be aware of that would interfere with your capacity to perform certain childcare activities      

My physician is: Name/Address: ____________________________________________________________

Physician Phone: _______________________ we have your permission to contact your physician/hospital, if

Necessary? ___Yes ___No

Signature: ____________________________________________ Date _________________

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Application Background Release Sample

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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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