Application For Employment

DISCLOSURE AND AUTHORIZATION REGARDING PROCUREMENT OF BACKROUND REPORTS

It is recognized and understood that the Fair Credit Reporting Act provides that anyone “who knowingly and willfully obtains information on a consumer from a consumer reporting agency under false pretenses” shall be fined not more than $2,500 or imprisoned not more than a year, or both

In connection with my application for EMPLOYMENT (including contract for services), I understand that investigative background inquiries are to be made on me which may include criminal convictions, motor vehicle, and other reports. These reports may include information as to my character, work habits, performance, education and experience along with response for termination of employments from previous employers. Further, I understand that you will be requesting information from various Federal, State, and other agencies which maintain records concerning my past activities relating to my driving, credit, criminal, civil and other experiences. If I include a current employer for verification, I may jeopardize my position within that company. I authorize without reservation, any party or agency contacted to finish the above mentioned information and release all parties involved from any liability and responsibility for doing so. I hereby consent to obtaining the above information from BACKROUND SOURCE INT’L and/or any of their licensed agents. This authorization and consent shall be valid in original, fax or copy form. I further authorize ongoing procurement of the above mentioned reports at any time during my employment (or contract).

Signature

*Responses to these are completely voluntary. You need not respond to have your application considered. However, without this information, we may be unable to distinguish you from another in the event we discover adverse information during our background investigation.

Name

First

Last

Date of Birth

Current Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

How long have you lived at this address?

Previous Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

How long did you live at this address?

Motor Vehicle Report

Name as it appears

License #

State Held

Untitled

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Application For Employment

Application for Employment

Step 1 of 6

PERSONAL INFORMATION

Employment History

Education

Miscellaneous

Please read the following carefully

PLEASE READ THIS STATEMENT CAREFULLY

DISCLOSURE AND AUTHORIZATION REGARDING PROCUREMENT OF BACKROUND REPORTS

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