APPLICANT AUTHORIZATION FORM

IN CONNECTION WITH, AND DURING MY EMPLOYMENT WITH YOU, I UNDERSTAND THAT INVESTIGATIVE BACKGROUND INQUIRIES ARE TO BE MADE ON MYSELF THAT MAY INCLUDE CONSUMER, CRIMINAL, DRIVING, ACADEMIC, AND OTHER REPORTS. THESE REPORTS WILL INCLUDE INFORMATION AS TO MY CHARACTER, WORK HABITS, PERFORMANCE AND EXPERIENCE, ALONG WITH REASONS FOR TERMINATION OF PAST EMPLOYMENT FROM PREVIOUS EMPLOYERS. FURTHER, I UNDERSTAND THAT YOU MAY BE REQUESTING INFORMATION FROM VARIOUS FEDERAL, STATE AND OTHER AGENCIES WHICH MAINTAIN RECORDS CONCERNING MY PAST ACADEMIC, EMPLOYMENT, DRIVING, CREDIT, CRIMINAL, CIVIL, MILITARY SERVICE, AND OTHER EXPERIENCES.

I AUTHORIZE, WITHOUT RESERVATION, ANY PARTY OR AGENCY CONTACTED BY THIS EMPLOYER TO FURNISH THE ABOVE INFORMATION:
 
APPLICANT'S SIGNATURE_________________________________ DATE_______________
PRINT FULL NAME____________________________________________________________
PREVIOUS LAST NAMES_______________________________________________________
SOC.SEC.NO._____-_____-_____
DATE OF BIRTH (requested to insure accurate retrieval of records)_____________
CITY AND STATE OF BIRTH___________________________________________________
DRIVER'S LICENSE NO._________________________________ STATE OF ISSUE_______
CURRENT ADDRESS_________________________________________________________
PREVIOUS ADDRESS (IF AT ABOVE FOR LESS THAN ONE YEAR)_____________________
CITY, STATE, ZIP___________________________________________________________
 
EMPLOYER INFORMATION
SUBMITTED FOR (APPLICANT NAME):__________________________________________
ACCOUNT NUMBER: ____________________________
REQUESTOR: _________________________________ (PRINT NAME)
EMAIL:______________________________________
COMPANY: ___________________________________
 
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