CONSENT TO BACKGROUND SEARCH AND
INVESTIGATION
The undersigned
hereby authorizes (name of company) ___________________________________
(hereinafter referred to as "Company") and/or its agents to make an
investigation of my background, references, character, past employment,
credit reports, education, and criminal history record information which
may be in any state or local files, including those maintained by both
public and private organizations, and all public records, for the purpose
of confirming the information contained in my application and/or obtaining
other information which may be material to my qualifications for
employment. A telephone facsimile (fax) or xerographic copy of this
consent shall be considered as valid as the original consent.
Prior
 to taking any
adverse action as a result of such investigation, Company shall provide to
me a copy of the consumer report which caused such adverse action and a
summary of my rights under the Fair Credit Reporting Act.
I
release
Company and/or its agents and any person or entity which provides
information pursuant to this authorization from any and all liabilities,
claims, or lawsuits in regard to the information obtained from any and all
of the above-referenced sources.
The following is my true and complete
legal name, and all information is true and correct to the best of my
knowledge:
True and Complete
Legal Name: First:_____________________
Middle:_____________________ Last:_____________________
Maiden or Other Names
Used:________________________________________ Dates Used:_______________
Present Street Address:____________________________________________ Years
of residence: 20__ to 20__
City:___________________________________
County:_______________ State:_____________ Zip:_______
Previous Street Address:
__________________________________________ Years of residence: 20__ to
20__
City:__________________________________ County:________________
State:_____________ Zip:_______
Other cities and states lived in during
the past seven years:
City:________________________________________
State:_____________ Years of residence: 19__ to 19__
City:________________________________________ State:_____________
Years of residence: 19__ to 19__
City:________________________________________ State:_____________
Years of residence: 19__ to 19__
Driver's License
Number:_____________________________________________ State of
Issue:_____________
Date of Birth: _____________________
Social Security Number:_____________________________________
Signature:_________________________________________________________
Date:___________________
Note: The above information is required
to ensure positive identification and is in no manner used as
qualification for employment.
COMPANY REQUEST
FOR PROCESSING
![[ ]](images/_consent_files/checkbox.gif) Employment verification
 # of employers
to verify: _____ |
|
Professional reference
# of references
to verify: _____ |
|
Education Verification
|
| Criminal History |
|
Credit History |
|
Professional License
Verification |
| Motor Vehicle Record
|
|
Social Security Number Verification
|
 If relevant to request, include job
history, reference names and tel numbers, and educational
background.
Requestor:
______________________________________
Company Tel No: (____)
_____________
Company Fax No: (____) _____________
Fax to MSI Investigations at: 603-298-6080
|
