Background Authorization Form

Personal Information

Name: ________________________ SSN_____________- __________________- _______________

**Previous Names Used: _____________________________________________________________________________

Current Home Address:_______________________________________________________________________________

Street Address (No P.O. Boxes) City State Zip Code County

How long have you lived at current address? ___________

Previous Address: ____________________________________________ ___________________

Street Address (No P.O. Boxes) City State Zip Code County

How Long? ____________________

**Date of Birth: _____ / _____ /___________ Driver’s License Number: _______________________ State: _________

Have you ever been convicted of a crime other than minor traffic offenses? Y_______ N_______
If yes, proved explanation:

Year of Offense: County offense was committed: Offense Description: _______________________________

**THIS INFORMATION IS REQUIRED IN ORDER TO CONDUCT AN ACCURATE CRIMINAL BACKGROUND SEARCH AND WILL
NOT BE USED AS CRITERIA IN THE HIRING PROCESS, AS DESCRIBED BY THE AGE DISCRIMINATION ACT OF 1967.

In connection with my application for employment, (including contract for services) with you, I understand that investigative background inquiries are to
be made on myself including consumer investigative criminal convictions. Further, I understand that you will be requesting information from various
Federal, State, and other agencies, which maintain records concerning my past activities relating to any criminal experiences.

I acknowledge that I have been counseled that a person or entity may not procure or cause to be prepared an investigative consumer report on
any consumer unless it is clearly and accurately disclosed to the consumer, that an investigative consumer report – including all applicable
information as to his or her character, general reputation, personal characteristics, mode of living, education history, driving history and
employment history – may be made. If you are denied employment because of the consumer investigation, it is your right under the Fair Credit
Reporting Act (Law 91-508) SS 606. to have the name of the agency or agencies from whom information concerning you was obtained. You
are also entitled to receive free copies of the information supplied by those agencies within sixty days upon written request. You have the right
to directly dispute with the consumer reporting agency the accuracy and completeness of any information furnished by that agency.

I authorize without reservation, any party or agency contacted by this employer to furnish the above mentioned information.

I release BACKGROUND NETWORK, INC and any other person and/or agencies from any suits, liens, judgments, damage and/or liability resulting
from this process.

The above information is used solely for inquiries and criminal history checks.

Falsifying any information on this release form will constitute grounds for immediate dismissal or declining any pending job offers.

Applicant’s Signature: _________________________________________ Date: ______________/____________/___________

For residents of CA, MN and OK: Fair Credit Reporting Act Notification
You will be provided with a free copy of any consumer reports or You have the right to receive a copy of your consumer credit report
investigative consumer reports if you check the box below. should one be requested for employment reasons.

□ By checking this box, I request a free copy of the report. □ By checking this box, I request a free copy of the report.
 Employment Information

1) Current Employer: ______________________________________________ Dates Employed: from ______________ to _______________

Employer Address: ________________________________________________________________________________________________________

Street Address (No P.O. Boxes) City State Zip Code County

Employer Phone #: ______________________________________ Position: _____________________________________________

Supervisor or Contact: _____________________________________________________________________________________________________

Ok to Contact? Y_______ N_______

2) Previous Employer: ______________________________________________ Dates Employed: from ______________ to _______________

Employer Address: ________________________________________________________________________________________________________

Street Address (No P.O. Boxes) City State Zip Code County

Employer Phone #: ______________________________________ Position: _____________________________________________

Supervisor or Contact: _____________________________________________________________________________________________________

Reason for leaving: _______________________________________________________________________________________________________

Ok to Contact? Y_______ N_______

Education History

1) School Name: _________________________________________________________________________________________________________

Location: ______________________________________________________________________________________________________________

Dates: from ______________ to _______________ Graduation Date: ____________________________

Degree/Diploma earned: ______________________ Major: ____________________________________

1) School Name: _________________________________________________________________________________________________________

Location: ______________________________________________________________________________________________________________

Dates: from ______________ to _______________ Graduation Date: ____________________________

Degree/Diploma earned: ______________________ Major: ____________________________________

Education History
Name Address Phone