Employee Background Report

EMPLOYEE BACKGROUND REPORT

Applicant Name:   Other names used:

Personal Information

Phone:   Email:

Date of Birth:   Last 4 of SSN:   Driver's License #:

Position Information

Anticipated Start Date:   Proposed Salary / Rate:

Employment History (Most Recent First)

Title/Position:   Start Date:   End Date:

Title/Position:   Start Date:   End Date:

Education

Graduation / Completion Date:   Major / Field:

Professional References (Provide three)

Phone:   Email:   Relationship:

Phone:   Email:   Relationship:

Phone:   Email:   Relationship:

Background Checks Requested / Results

Criminal Records Check      Result:

Employment Verification      Result:

Education Verification      Result:

Motor Vehicle Record      Result:

Credit Check (if applicable)      Result:

Legal Disclosures, Consent and Certification

At-Will Employment: I acknowledge that any offer of employment and continued employment with the company is on an at-will basis, unless a separate written agreement signed by an authorized company representative states otherwise.

Equal Opportunity Statement: The company provides equal employment opportunities to all applicants and employees without regard to race, color, religion, sex, national origin, age, disability, or any other protected characteristic under applicable law.

Authorization to Obtain Consumer/Investigative Reports: I hereby authorize the company, its agents and contracted screening providers to obtain consumer reports and investigative consumer reports about me for employment purposes. These reports may include, but are not limited to, criminal history, driving records, credit reports (where job related), education and employment verifications, professional license verification, and other relevant records. I understand such reports may contain information about my character, general reputation, personal characteristics, and mode of living.

Consent to Contact: I authorize the company and its agents to contact any references, prior employers, educational institutions, licensing authorities, governmental agencies and other persons or entities for the purpose of verifying information I have provided and otherwise evaluating my suitability for employment. I release those parties and the company from any liability arising from such inquiries.

Applicant Certification: I certify under penalty of perjury that the information I have provided on this form is true, accurate and complete to the best of my knowledge. I understand that any materially false, misleading, or omitted information may result in revocation of an offer of employment or termination of employment if employed.

Background Disclosure Acknowledgement: I have been informed that adverse information discovered in a background check may be considered in making employment decisions. I understand that I will be provided with required notices and an opportunity to dispute or explain any adverse information as required by applicable law prior to any final adverse decision.

Consent Affirmation: I consent to the background checks and verifications described above and authorize release of information as stated.

Review (Human Resources Use Only)

Review Date:   Overall Clearance:

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