| In connection with my application for employment { including contract for services,or volunteer services) I understand that my consumer reports or investigative consumer reports which may contain public record information, may be requested or made on me including Criminal Records, (State, County, Federal or International) Driving Records, Educational Records, Prior Employer Verification, OFAC (Office Of Foreign Asset Control), Interpol Fugitive Check, Past Address Trace, Drug Test and others. These reports will include experience along with reasons for termination of past employment. Further I understand that you will be requesting information from various Federal, State, County and other agencies which may contain may past actives. I agree that a fax copy of this authorization has the same effect as an original.
I hereby authorize the release and hold harmless any person, firm or entity that discloses matters in accordance with this authorization, as well as from any liability that might otherwise result from the request for use of and/or disclosure of any or all of the foregoing information. I hereby authorize without reservation, any part or agency contracted by this employer to furnish the above mentioned information. In addition I understand I may be asked to submit to a drug test, contingent to employment.
I understand that I have the right to make a request of my employer upon proper identification and the payment of any authorized fees, for the information in its files on me at that time of my request.
I further authorize ongoing procurement of the above mentioned reports at anytime during my employment {or contract }
Print your name:__________________________________________________
Current Address__________________________________________________
Previous Address_________________________________________________
City_______________________ State_____________ Zip_______________
Social Security Number____________________________________________
Drivers License State___________ Driver License Number________________
For Identification purpose:
Date Of Birth:
Month_______ Day________ Year_______Race______Gender___________
Other or former names____________________________________________
Professional License:
State___________Type___________________Number__________________
Educational History:
State_________Degree_____________School attended__________________
Years attended________________
Signature___________________________________ Date_________________ |