Authorization & Background Check Information

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.

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

For an electronic signature (type in your full name for your e-signature)

Date

Background Check Information

Name

First Middle Last

Date of birth

Social Security Number

Driver’s License Number

State Issuing License

Enter any other names used (including maiden names)

Addresses Within the Past Seven Years

Present Full Address

Street Address City State / Province / Region ZIP / Postal Code Country

Prior Address

Address

From (Month/Day/Year)

To (Month/Day/Year)