Background Check Release Form-Employment printable pdf download

BACKGROUND CHECK RELEASE FORM-Employment

PER FCRA: 1) Signing this release authorizes a background check. 2) You may not be offered a position based on it. 3) Your

employer will advise you if that’s their intention. You can review the report and dispute errors prior to official turndown.

Social Security #: _______-____-_______ Gender: _______ Race: ____________ Date of Birth ___/___/___ (only used to ensure accuracy of records)

Names:

Last: _______________________________First:________________________ Middle: _____________

Others:_______________________________________

Address history:

Present: _______________________________City, ST____________________ County _________Years ___

Prior: _________________________________City, ST ___________________ County _________ Years___

Any counties resided in last 7 years: ___________________________________________________________

Driver’s license number: ________________________ State issued: ___________________________

Conviction history: List all convictions including traffic: Please indicate “TR’ for Traffic, “M” for misdemeanor, and “F” for felony:

Year of offense

Offense

Where occurred – City, State, County

Level – TR, M, F

________________

_______________________________

________________________________________________

____________

________________

_______________________________

________________________________________________

____________

________________

_______________________________

________________________________________________

____________

I hereby authorize the release to _______________ Corporation and Background Bureau, Inc., (BBI) an independent pre-employment screening agency, of any information held by any parties

regarding my prior employment , criminal, credit, driving, workers comp. and educational history as well as information regarding my general character and reputation for employment purposes. I

release any providers of such information from any liability for providing same. I understand the information may be reviewed initially and periodically by BBI and reported to my

prospective/actual employer. I agree that an investigative consumer report may be requested, which may contain information pertaining to my character, general reputation, personal

characteristics, and mode of living obtained through personal interviews.

I authorize and request any federal, state, or local agency, college/university, former employer, and other persons to provide information or records concerning my military records, character,

employment, credit history, motor vehicle history, drug test results, academic records, licenses and certifications, or any other information requested by BBI. I understand that BBI is a consumer

reporting agency and that while reports are generally written in plain terms, BBI will provide a written explanation in response to any questions that I may have concerning my report.

I understand that any consumer report or investigative consumer report will be used only for a permissible purpose under the Fair Credit Reporting Act (FCRA). Those purposes include

evaluation for employment, promotion, reassignment or retention as an employee. Also, I understand that upon a conditional offer of employment, the report may contain medical inquiries and

workers’ compensation history, subject to rules under the Americans with Disabilities Act.

I acknowledge my right to request from BBI, subject to identification verification, the nature and scope of all information in its files concerning my background at the time of my request, including

sources of information, and the recipients of any reports about me which BBI has furnished within the two year period preceding my request. BBI may be contacted at 2019 Alexandria Pike,

Highland Heights, KY 41076 or at (800) 854-3990.

I agree falsification may make me ineligible for employment or subject to immediate dismissal, if hired. I further acknowledge that BBI is relying on third party information , is unable to guarantee

the accuracy of the data reported to it, and I therefore release BBI, my prospective employer, and their respective owners, officers, agents and employees from any and all liability arising out of

errors or omissions. If not hired, based on the report, I understand I have rights under FCRA laws including the right to review my report and correct errors.

Signed__________________________________

Dated_____________

CA, OK, MN, NY Residents:Check here to receive report.____

COVER SHEET (EMPLOYER USE ONLY) FAX RELEASE FORMS TO: 859-781-5888

EMAIL:

Client:

Attn:

Ph:

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