Employment Background Testing

EMPLOYMENT BACKGROUND TESTING AUTHORIZATION

Personal Information

Date of Birth:    Social Security Number:

Position Information

Proposed Start Date:    Proposed Salary/Rate:

Employment History (Most Recent First)

Employer 1

Employer 2

Education

Professional References

Reference 1

Reference 2

Reference 3

Background Testing Consent and Authorization

By signing this document I authorize the prospective employer, its agents, and designated screening providers to obtain background reports and test results for employment purposes, including but not limited to criminal history, motor vehicle records, credit history where job-related, education and credential verification, prior employment verification, professional license verification, drug and alcohol testing, and fingerprint-based records checks where required by law or position. I understand that information obtained may be used in whole or in part to make employment decisions.

I authorize all persons and entities that receive a copy of this authorization to release information, records, reports and other data pertaining to me to the prospective employer and its authorized agents and contractors. I hereby release such persons and entities, and the prospective employer and its agents, from all liability for damage that may result from furnishing such information. I understand that I may be required to provide identification documentation to facilitate these checks.

Conviction Disclosure — Have you ever been convicted of a felony?   Yes No

Legal Disclosures

At-Will Employment: I understand that submission of this authorization and any background test does not constitute an offer or guarantee of employment. If an offer of employment is extended and accepted, the employment relationship is at-will unless otherwise specified in a separate signed agreement.

Equal Opportunity: The prospective employer provides equal employment opportunity and does not discriminate on the basis of any protected characteristic. Background information will be considered in a manner consistent with applicable law.

Applicant Certification and Authorization

I certify that the information I have provided on this form is true and complete to the best of my knowledge. I understand that any misrepresentation or omission may be grounds for denial of employment or, if employed, termination. I authorize the release and disclosure of the requested background and testing information and understand that results may affect my eligibility for employment. I further acknowledge that a conditional offer of employment may be withdrawn based on the results of required background checks or tests when such results are relevant and job-related.

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