Employee Background Clearance Request

EMPLOYEE BACKGROUND CLEARANCE REQUEST

Employee Name:    Employee ID: 

Department:    Position/Title: 

Hiring Manager / Supervisor:    Proposed Start Date: 

Personal Information

Date of Birth:    Last 4 of SSN: 

Primary Phone:    Email: 

Background Check Authorization

I authorize the Company and its designated agents to obtain consumer reports, criminal history records, motor vehicle records, credit reports where job-related, and other investigative reports necessary to evaluate my suitability for employment or continued employment. I understand such reports may include information about my character, general reputation, personal characteristics and mode of living. I further authorize previous employers, educational institutions, references, and other persons to provide the Company with any relevant information. I release all parties from liability in providing this information.

Please indicate authorization for the following checks (check all that apply):

Criminal background check

Credit report (if applicable to position)

Motor vehicle / driving record

Drug and alcohol screening

I acknowledge that a conditional offer may be contingent upon satisfactory completion of the checks identified above. I understand that an adverse result may affect my eligibility for hire or continued employment. If an adverse action is contemplated based on a consumer report, I will be provided with required notices and an opportunity to respond in accordance with applicable law.

Prior Address History (past 7 years)

Employment History (Most Recent First)

Job Title:    Start Date:    End Date: 

Job Title:    Start Date:    End Date: 

Education

Graduation Date: 

Professional References

Phone:    Email: 

Phone:    Email: 

Phone:    Email: 

Legal Disclosures

At-Will Employment: Nothing in this request or in any related communications modifies the at-will nature of employment. Either the employee or the Company may terminate employment at any time, with or without cause or notice, unless otherwise expressly provided in a signed written agreement.

Equal Opportunity: The Company is an equal opportunity employer. Decisions regarding hiring, promotion, discipline and termination are made without regard to race, color, religion, sex, national origin, age, disability, genetic information, veteran status or any other protected class under applicable law.

Applicant Certification & Authorization

I certify that all information provided on this form and any attachments is true, accurate and complete to the best of my knowledge. I understand that falsification, misrepresentation, omission or failure to disclose may disqualify me from employment or lead to discipline, including termination. I expressly authorize the Company to contact the persons and organizations named in this form and to obtain any information relevant to my background and qualifications.

I certify that the information provided is true and I authorize the background checks described above.

HR Use Only

Clearance Decision:  Cleared   Conditionally Cleared   Denied

Reviewed By:    Date: 

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