Background Release Form Disclosure and Consent
Find Out Investigations
In connection with my application for employment (including contract for service) with ___________________________________________(“the Company”), I understand that investigative inquiries may be obtained on myself by a consumer reporting agency, and that any such report will be used solely for employment-related purposes. I understand that the nature and scope of this investigation will include a number of sources including, but not limited to, consumer credit, criminal convictions, motor vehicle, and other reports. These reports will include information as to my character, general reputation, personal characteristics, mode of living, and work habits. Information relating to my
performance and experience, along with reasons for termination of past employment from previous employers, may also be obtained. Further, I understand that you will be requesting information from various Federal, State, County and other agencies that maintain records concerning my past activities relating to my driving, credit, criminal, civil, education, and other experiences.
I understand that if the Company hires me, it may request a consumer report or an investigative consumer report about me for employment-related purposes during the course of my employment. The scope of this investigation will be the same as the scope of a pre-employment investigation, and that the nature of such an investigation will be my continuing suitability for employment, or whether I possess the minimum qualifications necessary for promotion or transfer to another position. I understand that my consent will apply throughout my employment, unless I revoke or cancel my consent by sending a signed letter or statement to the Company at any time, stating that I revoke my consent and no longer allow the Company to obtain consumer or investigative consumer reports about me.
This Disclosure and Consent form, in original, faxed, photocopied or electronic form, will be valid for any reports that may be requested by the Company.
I authorize without reservation any party or agency contacted by this employer to furnish the above-mentioned information. I hereby consent to your obtaining the above information from Accurate Background, Inc. and/or any of their licensed agents. I understand to aid in the proper identification of my file or records the following personal identifiers, as well as other information, is necessary.
Print Name_________________________________________
___________________________________________________
Applicant Signature page one of two page document
Other Names Known By _______________________________________________
Social Security Number _______-_____-________
Date of Birth ___/___/____
The date of birth requested on this form is for verification of information and identification only and has no role in the selection process.
Driver License Number __________________State____________
Current Address ___________________________________________________
City _____________________________________ State ______ ZIP _________
This Disclosure and Consent form, in original, faxed, photocopied or electronic form, will be valid for any reports that may be requested by the Company.
Have you ever been convicted of a felony, or a misdemeanor involving any violent act, use or possession of a weapon or act of dishonesty for which the record has not been sealed or expunged?
If yes, please briefly describe the nature of the crime(s) the date and place of conviction and the legal disposition of the case at the bottom of this page.
This company will not deny employment to any applicant solely because the person has been convicted of a crime. The company however, may consider the nature, date and circumstances of the offense as well as whether the offense is relevant to the duties of the position applied for.
Are you currently out on bail, the subject of a current warrant for arrest, or released on your own recognizance pending trial? Yes_____ NO______
Print Name_______________________________________
Applicant Signature _______________________________
page two of two page document
Date_______________
Prospective Employer ________________________________________________
Other : ______________________________________________________________
______________________________________________________________
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