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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