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Pre-Employment Background Check Form

APPLICANT COMPLETE THE FOLLOWING
Release Authorization

I. In connection with my application for employment, I understand that an investigative consumer report may be requested that will include information as to my character, work habits, performance, and experience, along with reasons for termination of past employment. I understand that as directed by company policy and consistent with the job described, you may be requesting information from public and private sources about my workers' compensation injuries, driving record, court record, education, credentials, credit, and references.

II. Medical and workers’ compensation information will only be requested in compliance with the Federal Americans with Disabilities Act (ADA) and/or any other applicable state laws. According to the Fair Credit Reporting Act, I am entitled to know if employment is denied because of information obtained by my prospective employer from a consumer reporting agency. If so, I will be notified and given the name and address of the agency or the source which provided the information.

III. I acknowledge that a telephonic facsimile (FAX) or photographic copy shall be as valid as the original. This release is valid for most federal, state, and county agencies, including the Minnesota Department of Labor.

IV. Minnesota applicants only. If you want a copy of the report(s) ordered,  yes no. The report(s) will be sent by the reporting agency to you at the address below.

V. I hereby authorize, without reservation, any law enforcement agency, institution, information service bureau, school, employer, reference or insurance company contacted by Arizona Licensed Detective, or his agent, to furnish the information described in Section I.

The following information is required by law enforcement agencies and other entities for positive identification purposes when checking public records. It is confidential, and will not be used for any other purposes. I hereby release the employer and agents, and all persons, agencies, and entities providing information or reports about me from any and all liability arising out of the request for or release of any of the above mentioned information or reports.

Full Name:

Please print other names you have used

Home Address:

Signature


THIS PAGE CONTAINS SENSITIVE INFORMATION. KEEP ONLY IN SECURED FILES, SEPARATE FROM PERSONNEL RECORDS!

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EMPLOYER COMPLETE THE FOLLOWING
Order Form

DELIVER MY REPORTS VIA:

 Fax Mail Verbal

Social Security Verification

 Yes No

Driving Record

 Yes No

Motor Vehicle Registration

 Yes No

Workers’ Compensation History (Employer certifies that a conditional job offer has been made)

 Yes No

Credit (for employment purposes only)

 Yes No

Civil Records

 Municipal Superior Federal

Criminal Records

 Municipal Superior Federal

National Criminal Wants & Warrants

 Yes No

Bankruptcies, Tax Liens, Judgments

 Yes No

Verifications

Employment Verification

 Yes No

Employment References

 Yes No

Education/Academic Verification

 Yes No

Professional License

 Yes No

Personal References

 Yes No

Military Service Verification

 Yes No

Corporate Records Search

 Yes No

UCC Filings Search

 Yes No

Fictitious Business Name Search

 Yes No

Business Licensing

 Yes No

State Board of Equalization

 Yes No

Business Credit Report

 Yes No

Please submit copy of employment application or resume if available.

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