Employment Background Check Release Form

EMPLOYMENT BACKGROUND CHECK RELEASE FORM

Personal Information

Applicant Name:    Date of Birth:    SSN:

Position Information

Proposed Start Date:    Salary (annual or hourly):

Full-Time    Part-Time    Temporary/Contract

Employment History (Most Recent First)

Phone:    Supervisor:

Title:    From:    To:

Phone:    Supervisor:

Title:    From:    To:

Phone:    Supervisor:

Title:    From:    To:

Education

Major/Field:    Graduation Date:

References (Professional)

Phone:    Email:

Phone:    Email:

Phone:    Email:

Legal Disclosures and Consent

At-Will Employment: I understand that if I am hired, my employment will be on an at-will basis unless a contrary written agreement signed by an authorized company representative is in effect. Either the employer or I may terminate the employment relationship at any time, with or without cause or notice.

Equal Opportunity: The employer is an equal opportunity employer. Employment decisions are made without regard to race, color, religion, sex, national origin, age, disability, marital status, veteran status, or other protected status as required by applicable law.

Authorization to Obtain Background Information: I hereby authorize the employer, its agents and representatives to obtain background information about me for employment purposes. This authorization includes, but is not limited to, criminal history, driving record (motor vehicle report), education verification, employment verification, professional license verification, credit and financial reports where permitted by law, and reference checks. I authorize any person or entity that receives a copy of this release to furnish the above information.

Criminal History Check    Driving Record / MVR    Education Verification

Employment Verification    Credit Check (if applicable)    Professional License Verification

I understand that information obtained through background checks may be used in whole or in part to make employment decisions. I authorize any consumer reporting agency or other entity to release such information to the employer or its designated agents. I release all such parties from liability for providing such information and from any claims arising from the use of the information, to the extent permitted by law.

This authorization shall remain in effect for the duration specified below or for a period of twelve (12) months from the date signed, unless I revoke it in writing. I understand I may withdraw this authorization at any time by delivering written notice to the employer; however, withdrawal will not affect background checks already completed.

Authorization Effective Date:    Authorization Expiration Date:

Background and Legal Questions

Have you ever been convicted of a felony?    No    Yes

Applicant Certification and Acknowledgement

I certify that the information I have provided on this form and in any attachments is true, correct and complete to the best of my knowledge. I understand that falsification, omission or misrepresentation of information may result in refusal to hire, or discipline up to and including termination if discovered after hire.

I authorize the employer to contact previous employers, educational institutions, licensing authorities and references provided on this form for the purpose of verifying information and obtaining background information. I understand that I may be asked to provide additional identifying information (such as driver license number or fingerprint) when required for certain checks, and that providing such additional information is voluntary but may be required as a condition of employment.

By signing below I acknowledge that I have read and understand the foregoing and that I authorize the release of pertinent information as described above.

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