Background Check Disclosure And Authorization Form (Page 2 of 4) in pdf

AUTHORIZATION FOR BACKGROUND CHECKS

After carefully reading this Background Check Disclosure and Authorization form, I authorize the Company to order my

background report, including investigative consumer reports. I understand that the Company may rely on this authorization

to order additional background reports, including investigative consumer reports, during my employment without asking me

for my authorization again as allowed by law.

I also authorize the following agencies and entities to disclose to ADP Screening and Selection Services and its agents all

information about or concerning me, including but not limited to: my past or present employers; learning institutions,

including colleges and universities; law enforcement and all other federal, state and local agencies; federal, state and local

courts; the military; credit bureaus; testing facilities; motor vehicle records agencies; all other private and public sector

repositories of information; and any other person, organization, or agency with any information about or concerning me.

The information that can be disclosed to ADP Screening and Selection Services and its agents includes, but is not limited

to, information concerning my employment history, earnings history, education, credit history, motor vehicle history, criminal

history, military service, professional credentials and licenses and substance abuse testing.

I agree the Company may rely on this authorization to order background reports, including investigative consumer reports,

from companies other than ADP Screening and Selection Services without asking me for my authorization again as allowed

by law. I also agree that a copy of this form is valid like the signed original. I certify that all of my personal information on

this form is true and correct and understand that dishonesty will disqualify me from consideration for employment with the

Company, or if I am hired or already work for the Company, that my employment may be terminated.

Last Name __________________________________ First ________________________ Middle ____________________

Maiden/Other Names _______________________________________________ Years Used _______________________

Social Security Number _______________________________________________________________________________

Driver’s License Number ________________________________________________ State _________________________

FOR IDENTIFICATION PURPOSES ONLY:

Addresses Within The Past Seven Years (use a separate sheet as needed)

Present Street Address _______________________________________________________________________________

City/State/ZIP _______________________________________________________________________________________

Prior Street Address __________________________________________________________________________________

From _____/_______/______ (Month/Day/Year)

To _____/_______/______ (Month/Day/Year)

City/State/ZIP _______________________________________________________________________________________

______________________________________________________________

_____/_______/________

Signature

Date:

(Month/Day/Year)

If you live or work for the Company in California, Minnesota or Oklahoma: Check this box if you would like a free copy

of your background check report:

V0611

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Background Check Disclosure And Authorization Form Page 2