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CONFIDENTIAL
Organization Name
Background Check Authorization
Print Name:
(First)
(Middle)
(Last)
Former Name(s) and Dates Used:
Current Address Since:
(Mo/Yr)
(Street)
(City)
(Zip/State)
(Mo/Yr)
(Street)
(City)
(Zip/State)
(Mo/Yr)
(Street)
(City)
(Zip/State)
Previous Address From:
Previous Address From:
Social Security
Number:
Date of
Birth:
Telephone Number:
Drivers License Number/State:
The information contained in this application is correct to the best of my knowledge. I hereby authorize
(Organization Name) and its designated agents and representatives to conduct a comprehensive
review of my background causing a consumer report and/or an investigative consumer report to be
generated for employment and/or volunteer purposes. I understand that the scope of the consumer
report/ investigative consumer report may include, but is not limited to the following areas: verification of
social security number; current and previous residences; employment history, education b