Sample Tenant Check Release Form

Applicant Authorization and Consent for Release of Information

PLEASE READ CAREFULLY

I, the undersigned applicant, do hereby certify that the information provided by me for the purpose of the attached tenancy application is true and complete to the best of my knowledge. I understand that any false statement provided by me will be cause for denial of tenancy. 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 tenancy decision process.

This Authorization and Consent for Release of Information acknowledges that _____________________ may now conduct a verification and/or screening of my Previous Employment, Education, 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 tenancy with _______________________ is contingent upon a satisfactory background verification.

I have read and understand this Authorization and Consent for Release of Information, and I authorize the background screening. I authorize persons, current and former employers, and other organizations and agencies to provide all information that may be requested by the screening company. 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 application was denied based on information obtained for this background screening, and to receive upon written request, a disclosure of the public record information and of the nature and scope of the background screening report.

I acknowledge receipt of a copy of “A Summary of Your Rights Under the Fair Credit Reporting Act.”

Applicant’s Full Name (print):  ________________________________________________

Social Security Number: ________________________________  Date of Birth: _____________

D/L # and State: ____________________________________

Current Street Address: _________________________________________________
                        City: ________________________________________________________
              State & Zip: __________________________________________________

Phone Number: ____________________  

__________________________________________________________   Date:______________
Signature (must be signed by applicant)