Free background check form 39Free background check form 39Free background check form 39
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BACKGROUND CHECK RELEASE
FORM
NAME (First, Middle, Last):

_

FORMER/MAIDEN NAME(S) (If applicable):

EMAIL:

_

CURRENT ADDRESS:

DATE OF RESIDENCY (MM/YY):

CITY, STATE, ZIP:

PHONE: (

_)

PREVIOUS ADDRESS (IF CURRENT IS LESS THAN 7 YEARS):
CITY, STATE, ZIP:
*APPLICANT’S SOCIAL SECURITY NUMBER:

DATES OF RESIDENCY (MM/YY):

*DATE OF BIRTH:

/

_
/

DRIVER’S LICENSE NUMBER AND STATE ISSUED:
YEAR AND SCHOOL NAME OF MOST RECENT GRADUATION:
TYPE DEGREE/DIPLOMA RECEIVED:
CITY AND STATE:

_
_

DATE RECEIVED (MM/YY):

NAME AT TIME OF GRADUATION:

* This information will be used only for background screening purposes and will not be taken into consideration in any employment decisions.

Authorization of Background Investigation
I have carefully read and understand this Disclosure and Authorization form and the attached summary of rights under the Fair Credit
Reporting Act. By my signature below, I consent to preparation of background reports by a consumer reporting agency such as
HireR