For and in consideration of my application for potential employment with ________________________________, I hereby authorize and request that an "investigative consumer report" (background inquiry) be compiled regarding the undersigned. I understand that this inquiry may include information regarding my character, personal characteristics, mode of living, and general reputation.
By placing my signiture below, I acknowledge that this background inquiry may involve the request of any or all of the following (as allowed by law):
+ Any public record of criminal convictions.
+ Any incident of dishonesty, theft, moral turpitude, violence, or drug-related offenses reported by merchants, employers,
business or individuals.
+ Any credit bureau report.
+ Any driving history related to infractions or accidents.
+ Any previous employment records.
+ Any public, semi-public, or proprietary records from any record repository.
__________ (Initials of employee)
I hereby authorize and request the cooperation of any government or law enforcement agencies, credit bureaus, proprietary databases, former employers, business sources, or individuals called upon by ________________________________________,
or its authorized agent, Star Security Incorporated, in the release and disseminatin of the requested information.
_________ (Initials of employee)
I waive any further notice with respect to the inquires made by or on behalf of _______________________________________,
and agree to generally release and fully discharge __________________________________, and Star Security Incorporated, every such law enforcement agency, every such governmental agency, every such prior employer, every such credit bureau, database, or individual with regard to the release and dissemination of the requested information.
__________ (Initials of employee)
I understand that I may obtain a free copy of this "consumer report", where applicable, if an adverse action or decision is made based upon the information in the "consumer report". I must make a written request within 60 days of the adverse action/decision.
A photocopy of this authorization and release shall be considered as effective and valid as the original.
Employee, please complete all of the following information. (additional pages may be used, if needed):
Full Legal Name (please print):_____________________________________________________________________________
Previous names or aliases:_________________________________________________________________________________
Addresses for the last seven years:___________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________ _______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Social Security Number:_______________________________ Date of Birth:________________________________________
Driver's License #:___________________________________ Driver's License State:_________________________________
________________________________________________ ____________________________________________
Signature Date
The information requested above is done for the purpose of conducting a pre-employment and continued employment investigation only.