Employment Background Release Form

EMPLOYMENT BACKGROUND RELEASE FORM

Company Name:

PERSONAL INFORMATION

Date of Birth:    Social Security Number:

Phone:    Email:

POSITION INFORMATION

Proposed Start Date:    Salary / Rate:

EMPLOYMENT HISTORY (Most Recent First)

Employer 1

Job Title:    Dates Employed From: To:

Employer 2

Job Title:    Dates Employed From: To:

EDUCATION

Graduation Date:

REFERENCES

Reference 1

Reference 2

Reference 3

AUTHORIZATION TO OBTAIN INFORMATION / CONSENT

I hereby authorize the above-named Company and its agents to obtain consumer reports, investigative consumer reports, and to contact any references, former employers, educational institutions, licensing authorities, and other third parties for the purpose of evaluating my suitability for employment. I understand that such inquiries may include, where relevant, verification of my employment history, education, professional licenses, motor vehicle records, criminal history, credit history, and other background information. This authorization is given in connection with my application for employment and, if hired, shall remain in effect during my employment as permitted by law.

By checking the boxes below, I specifically authorize the Company to obtain the following information as applicable to the position:

Criminal record search and criminal history verification
Employment verification (past employers)
Education and professional credential verification
Motor vehicle record / driving history
Consumer credit report (only if job-related and permitted by law)
Professional references and licensure inquiries
Drug and substance screening where permitted

I understand that a consumer report or investigative consumer report may be requested in connection with my application for employment. I acknowledge receipt of this disclosure and authorize the release of such information to the Company. I further understand that, if adverse action is contemplated on the basis of information contained in any consumer report, the Company will provide me a copy of the report and a written summary of my rights under applicable law prior to taking such adverse action.

RELEASE AND INDEMNIFICATION

I release and hold harmless all persons, companies, institutions, and the Company from any and all liability arising from the release or use of information provided in connection with this background investigation, except where prohibited by law. I waive any right to pursue claims against any former employer, reference, consumer reporting agency, or other individuals or entities for providing truthful information to the Company. I agree to indemnify the Company and its agents for any claims, damages or costs arising from any false statements I have made in this application or this authorization.

LEGAL DISCLOSURES

At-Will Employment: If hired, I acknowledge that my employment will be at-will, unless otherwise expressly set forth in a written agreement signed by an authorized representative of the Company. Either I or the Company may terminate the employment relationship at any time, with or without cause or notice, unless otherwise required by law.

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

APPLICANT CERTIFICATION

I certify under penalty of perjury that all information provided in this form is true, complete, and correct to the best of my knowledge. I understand that falsification, omission, or misrepresentation may result in rejection of my application or disciplinary action up to and including termination of employment.

I authorize the Company to contact my previous employers and listed references.

I acknowledge that I have read and understand this Authorization to Obtain Information / Consent and agree to its terms.

Applicant Comments (optional):

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