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The purpose of this form is to notify you
that a consumer report will be conducted on you in the course of consideration
for employment.
I hereby authorize your company or any agent
of your company to contact any and all corporations, former employers,
credit agencies, educational institutions, law enforcement agencies, city,
state, county and federal courts and military services to release information
about my background including, but not limited to, information about my
employment, education, consumer credit history, driving record, criminal
record, and general public records history to the person or company with
which this form has been filed. This releases the aforesaid parties from
any liability and responsibility for collecting the above information.
This release shall remain in effect for the length of my employment.
I understand, I have the right to obtain
a free copy of this consumer report if, (1) Any adverse action/decision
is made based on the information in the consumer report, (2) If the request
is made in writing within 60 days of the adverse action.
I Believe to the best of my knowledge that
all information I have provided is accurate true and correct and that
I fully understand the terms of this release.
Write in Black Ink Only!
Name (Last):___________________________________________________________________
(First):_______________________________
(Middle):___________________________
List any other names used in the last 7 years:_______________________________________
Date of Birth: ____/_____/_____
Social Security Number:________-______-________
Drivers License Number:________________________ State of:_________________________
Phone Number (Day): (_____) ______-_________ (Evening)
(_____) ______-_________
Current Address:
______________________ City:____________ State:_____ Zip:_______ Dates:___/___
to ___/___
Previous Address:
______________________ City:____________ State:_____ Zip:_______ Dates:___/___
to ___/___
List the cities or towns you have lived in during the past 7 years. Use
reverse side if necessary.
______________________ City:____________ State:_____ Zip:_______ Dates:___/___
to ___/___
______________________ City:____________ State:_____ Zip:_______ Dates:___/___
to ___/___
______________________ City:____________ State:_____ Zip:_______ Dates:___/___
to ___/___
Signature:___________________________________________
Today's Date:____/____/____
TO BE FILLED OUT BY COMPANY REQUESTING INFORMATION:
Company Requesting Information:_____________________________________________
Fax Number:________________
Name Of Person To Return Information To:______________________________________
Phone Number:______________
Information Requested:
_____ Criminal History _____Civil History _____Credit
Report _____Social Security Verification _____ DMV History
Disclaimer:
While the information contained in the reports provided as been
obtained from public records data sources deemed reliable, its
accuracy cannot be guaranteed due to potential human error in
the actual recording of the record. Since this information is
not owned by Employer's Investigative Services, and since public
records data on any one individual, group of individuals, company
or companies can be contained in more than one repository Employers
Investigative Services can only rely on its accuracy from the
public records data source presently available at the time of
the search. This information is furnished for you exclusive use
and accepted by you without any liability on the part of E.I.S.,
its sources, officers, agents or employees. Furthermore you agree
to indemnify E.I.S. , Its sources, agents and employees of any
liability for the use of this information and shall agree that
the right to obtain and the purpose for this information, for
you exclusive use, is fully within the appropriate laws which
apply to the permissible purpose of retrieving background information
on an individual's criminal record history, credit history and/or
workers compensation claim history.
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