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Pre-Employment Background Check Form

APPLICANT COMPLETE THE FOLLOWING
Release Authorization

    I. In connection with my application for employment, I understand that an investigative consumer report may be requested that will include information as to my character, work habits, performance, and experience, along with reasons for termination of past employment. I understand that as directed by company policy and consistent with the job described, you may be requesting information from public and private sources about my workers' compensation injuries, driving record, court record, education, credentials, credit, and references.

    II. Medical and workers’ compensation information will only be requested in compliance with the Federal Americans with Disabilities Act (ADA) and/or any other applicable state laws. According to the Fair Credit Reporting Act, I am entitled to know if employment is denied because of information obtained by my prospective employer from a consumer reporting agency. If so, I will be notified and given the name and address of the agency or the source which provided the information.

    III. I acknowledge that a telephonic facsimile (FAX) or photographic copy shall be as valid as the original. This release is valid for most federal, state, and county agencies, including the Minnesota Department of Labor.

    IV. Minnesota applicants only. If you want a copy of the report(s) ordered, yesno. The report(s) will be sent by the reporting agency to you at the address below.

    V. I hereby authorize, without reservation, any law enforcement agency, institution, information service bureau, school, employer, reference or insurance company contacted by Arizona Licensed Detective, or his agent, to furnish the information described in Section I.

    The following information is required by law enforcement agencies and other entities for positive identification purposes when checking public records. It is confidential, and will not be used for any other purposes. I hereby release the employer and agents, and all persons, agencies, and entities providing information or reports about me from any and all liability arising out of the request for or release of any of the above mentioned information or reports.

    Full Name:

    Please print other names you have used

    Home Address:

    Signature


    THIS PAGE CONTAINS SENSITIVE INFORMATION. KEEP ONLY IN SECURED FILES, SEPARATE FROM PERSONNEL RECORDS!

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    EMPLOYER COMPLETE THE FOLLOWING
    Order Form

      DELIVER MY REPORTS VIA:

      FaxMailVerbal

      Social Security Verification

      YesNo

      Driving Record

      YesNo

      Motor Vehicle Registration

      YesNo

      Workers’ Compensation History (Employer certifies that a conditional job offer has been made)

      YesNo

      Credit (for employment purposes only)

      YesNo

      Civil Records

      MunicipalSuperiorFederal

      Criminal Records

      MunicipalSuperiorFederal

      National Criminal Wants & Warrants

      YesNo

      Bankruptcies, Tax Liens, Judgments

      YesNo

      Verifications

      Employment Verification

      YesNo

      Employment References

      YesNo

      Education/Academic Verification

      YesNo

      Professional License

      YesNo

      Personal References

      YesNo

      Military Service Verification

      YesNo

      Corporate Records Search

      YesNo

      UCC Filings Search

      YesNo

      Fictitious Business Name Search

      YesNo

      Business Licensing

      YesNo

      State Board of Equalization

      YesNo

      Business Credit Report

      YesNo

      Please submit copy of employment application or resume if available.

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