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Human Resources

School:

BACKGROUND CHECK FORM
Please be advised that your employment is contingent upon successful completion of this background check.
I prefer to submit my information online directly to Pepperdine’s background screening company.
Please email my secure login information to this email address:
.
(if you prefer to submit your information online, you do not need to complete the information below)

EMPLOYEE INFORMATION
First Name:

Middle:

Last Name:

Other Names Used:

Years Used:

Current Address:

Since (dates): (MM/YY)

Social Security Number:

Date of Birth:

Gender:

Daytime Phone Number:

Driver’s License Number:

State of Issuance:

Male
Female
Email Address:

EMPLOYMENT HISTORY (two most recent)
Company/Employer Name:

1
If. this is your present employer, may we contact this
employer?
EmployerYes
City & No
State:

2

Dates of Employment: (MM/YY-MM/YY)
Position/Title:
Employer Phone Number:
Dates of Employment: (MM/YY-MM/YY)

Company/Employer Name:

If this is