Employment Background Check Certification

EMPLOYMENT BACKGROUND CHECK CERTIFICATION

Personal Information

Position Information

Full-time    Part-time    Temporary    Contract

Authorization for Background Screening

I hereby authorize the employer and any of its agents, representatives or service providers to procure consumer reports, investigative consumer reports and other information about me for employment purposes. This information may include, but is not limited to, verification of social security number, criminal history, credit history, driving/motor vehicle records, education, employment history, professional licenses, and drug/alcohol testing as permitted by law. I understand that any information obtained will be used only for employment-related decisions.

Criminal background check    Sex offender registry search    Credit history check    Employment verification    Education verification    Drug/alcohol screening    Motor vehicle record check

Disclosure and Consent

I understand that a consumer reporting agency may prepare a consumer report and/or investigative consumer report. I understand that I may request a copy of any report prepared about me by providing written notice to the employer within a reasonable time after receipt of notice that a report will be or has been obtained. Where required by law, I will be provided with advance notice and a separate written disclosure and authorization before an investigative consumer report is obtained. I further understand that any adverse action taken by the employer based on the information obtained will be conducted in accordance with applicable law and I will be provided any required adverse action notices.

By signing below I authorize all persons, schools, my current and former employers, and other entities to release to the employer and its agents any and all information requested in connection with the background screening process. I release such persons and entities from any liability for providing such information and from any claims arising from the release or use of such information to the extent permitted by law.

Applicant Certification and Affirmations

I certify that all information provided on this form and any attachments is true, complete, and correct to the best of my knowledge. I understand that falsification, omission, or misrepresentation of information may constitute grounds for denial of employment or immediate termination of employment if hired. I hereby authorize investigation of all statements contained herein and release from liability any person or organization obtaining or supplying such information.

Employment History (most recent first)

Education

Professional References

Criminal Conviction Disclosure

Have you ever been convicted of a crime, pled nolo contendere, or received a deferred adjudication? (Do not include non-felony traffic offenses unless specified.)

No    Yes — if yes, provide details below

Legal Notices and Acknowledgements

Equal Employment Opportunity: The employer provides equal employment opportunity to all applicants and employees without regard to race, color, religion, sex, national origin, age, disability, or any other status protected by applicable law. This statement does not create any contractual rights beyond those provided by law.

At-Will Employment: If hired, I understand that my employment relationship with the employer will be at-will, meaning either the employer or I may terminate the relationship at any time, with or without cause and with or without notice, unless a separate written agreement signed by authorized representatives specifies otherwise.

I understand that completing this certification and authorizing background checks is a condition of continued consideration for employment and does not constitute a promise or guarantee of employment. I acknowledge receipt of a copy of the consumer disclosure and consent contained herein by my signature below.

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