Authorization for Release of Information
and Background Check

 

I understand that in processing my application, an investigation may be made in which information is obtained through personal interviews and a review of information held by law enforcement or other governing agencies. I authorize you to verify my past employment, education records, criminal records, motor vehicle records, personal references and other job related data provided on this application or via the interview process. I authorize the appropriate individuals, companies, institutions or agencies to release information and I release them from any liability as a result of such inquiries or disclosures. I have the right under the “Fair Credit Reporting Act” to make a written request within a reasonable period to receive detailed information about the nature of this investigation.

 

I understand that any offer for a staff or volunteer position is contingent upon the results of my investigative report. I also understand that false or misleading statements in this application or concealment of requested facts may be considered cause for dismissal.

 

In order for this investigative report to be completed, I must provide the information requested on the reverse side of this form. I understand that my failure to completely and accurately complete this form, or my misrepresentation or omission of any facts called for therein, may result in termination of employment or the withdrawal of any job offer.

 

I understand that a conviction does not automatically mean that I will not be offered a position. The nature of the conviction, the circumstances surrounding the conviction and how long ago the conviction occurred are all factors that will be evaluated. I further understand this information will be used only for the limited purpose of preparing the investigative report.

 

 

 

Name (please print)                                                                                                                 

                                    Last                                                        First                                        Middle

 

 

Signature                                                                                                                                 

Date

 

 

Required Information for Background Check

Please Print Clearly

 

Name                                                                                                                                      

Last                                                                        First                                                        Middle

 

Alias/Maiden Name                                                                                                                  

 

Date of Birth          /      /           Sex  M  F      Social Security Number         -            -       

 

Drivers License Number                                                                                                           

 

Current Address                                                                                                                       

Street                                                                                      Apartment Number

                                                                                                                                               

City                                                                         State                       Zip Code

 

Previous Address                                                                                                                     

Street                                                                                      Apartment Number

If within seven years                                                                                                                                                          

City                                                                         State                       Zip Code

 

 First Time Applicant

 Repeat Applicant

 

Background Check Findings

For Office Use Only

 

Position Applied For                                                                                                                 

 

Date Background Check Completed           /       /          

 

Agencies Contacted:

                                                                               

                                                                               

                                                                               

 

Method of Background Check:

 Internet

 Mail/Fax

 In-Person

 Contracted Out – Agency Name                                                                              

 

Staff Person Initiating Check                                                                                                     

Please Print

 

Signature                                                                                               Date        /       /