Employee Database Check

EMPLOYEE DATABASE CHECK

Date of Request:    Requesting Department:

Personal Information

Position Information

Employment Status: Full-time Part-time Contractor

Start Date:    Current Salary/Rate:

Databases and Records Requested for Review

Select all databases and records to be checked. The authorized reviewer will have access only to records indicated below.

Payroll records (earnings, deductions, pay history)
Tax withholding and reporting records
Benefits enrollment and claims records
Performance evaluations and merit action records
Disciplinary and corrective action records
Training, certification and credential records
Background check reports (criminal history, where applicable)
Employment eligibility and I-9 documentation review
Other:

Purpose of Access

The undersigned authorizes access to the selected records for the following purpose(s):
Internal audit or compliance review
Benefits administration or eligibility determination
Investigation of a workplace incident or complaint
Pre-employment or contingent hire verification
Other:

Authorization and Release

I authorize the Human Resources department and its authorized representatives to access, inspect and obtain copies of the records and databases specified above. This authorization includes, where applicable, contacting prior employers and third-party data providers to verify employment history, payroll, benefits, disciplinary actions, training, and background information necessary to the stated purpose.

I expressly authorize those entities to release requested information to the company and release the company and any person or organization providing information from any liability arising from such disclosure, provided the disclosure is conducted in accordance with applicable law. I understand that disclosures made in reliance on this authorization may include sensitive information and that the company will treat such information as confidential and limit distribution to personnel with a legitimate business need to know.

I acknowledge that I may revoke this authorization in writing, but that revocation will not apply to information already obtained in reliance on this authorization. I understand that refusal to authorize access to certain records may affect the company's ability to complete the stated purpose and may affect employment decisions where lawfully permitted.

Applicant Certification

By signing below I certify that the information provided on this form is true and complete to the best of my knowledge. I understand that knowingly providing false or misleading information may result in disciplinary action up to and including termination of employment where permitted by law.

I authorize the company to conduct the requested verifications. I understand that copies of reports and records obtained under this authorization may be retained in the employee's personnel file or in secure electronic records for legitimate HR business purposes in accordance with company policy.

I consent to release of the specified records to authorized reviewers and certify that I have provided truthful consent for release of records related to me.

I certify that all information on this form is true and I authorize the requested database checks.

Employment History (most recent first)

Education

Graduation Date:    Major/Field:

Professional References

Authorization to Contact and Background Checks

I authorize contact with previous employers to verify employment dates, title, and reason for separation.

I authorize the company to conduct background checks, criminal record checks, and other verifications as appropriate and permitted by law.

Confidentiality and Record Retention

Records and reports obtained under this authorization will be maintained in secure HR systems and retained only as necessary for legitimate business purposes or as required by law. Access to retrieved records is limited to authorized personnel with a specific need to review the information.

Any dissemination of personally identifiable information obtained pursuant to this authorization outside authorized personnel is prohibited and may subject the disclosing individual to disciplinary action.

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