| Sample Background Screening Release Form |
| Applicant Authorization and Consent for Release of Information |
| PLEASE READ CAREFULLY |
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I, the undersigned applicant, do hereby certify that the information provided by me for the purpose of the attached employment application is true and complete to the best of my knowledge. I understand that any false statement provided by me will be considered as cause for possible dismissal. All results of the research into my background will be proprietary and kept confidential. The information obtained will not be provided to any parties that are not part of the hiring decision. This Authorization and Consent for Release acknowledges that _____________________ may now conduct a verification and/or screening of my Previous Employment, Education, Driving Record, References, Tenancy, and any Criminal History Record information pertaining to me that may be in the files of any Federal, State, or Local Criminal Justice agency in any State, Territory, Possession, or Jurisdictional Area of the United States of America, or other Nations or Countries. I acknowledge by my signature below that employment with __________________ is contingent upon a satisfactory background verification. I have read and understand this release and consent, and I authorize the background search. I authorize persons, current and former employers, and other organizations and agencies to provide all information that may be requested. I hereby release all of the persons and agencies providing such information from any and all claims and damages connected with their release of any requested information. I agree that any copy of this document is valid as the original. I do hereby agree to forever release and discharge _____________________, their agents and their associates, to the full extent permitted by law from any claims, damages, losses, liabilities, costs and expenses, or any charge or complaint filed with any agency arising from the retrieving and reporting of this information. According to the Federal Fair Credit Reporting Act, I am entitled to know if my employment application was denied based on information obtained by prospective employer, and to receive upon written request, a disclosure of the public record information and of the nature and scope of the background screening report. Applicant’s Full Name (print): ________________________________________________ Social Security Number: ________________________________ Date of Birth: _____________ D/L # and State: ____________________________________
Current Street Address: _________________________________________________ Phone Number: ____________________
__________________________________________________________ Date:______________
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