Please Print Out This Form And Fax or E-mail It Back
   
Release Form For Consumer Reports

In connection with my application for employment { including contract for 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 consumer credit, criminal records, driving records, educational records, prior employer verification, workers compensation claims 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, local and other agencies which may contain may past actives.
   
I hereby authorize without reservation, any part or agency contacted 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 have the right to make a request of CHAPPELLE ENTERPRISES NATIONWIDE PRE-EMPLOYMENT BACKGROUND SCREENING SPECIALISTS, upon proper identification and the payment of any authorized fees, for the information in its files on me at the 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_________________