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BACKGROUND CHECK AUTHORIZATION AND RELEASE FORM
Last Name
First Name
Middle Name
Soc. Sec. #
Driver Lic # (MVR Only)
Date of Birth
Maiden and all other names used
Present Address
City
Length at present address
(If less than 7 years please provide previous addresses)
Prior Address
City
State
Zip
County
Prior Address
City
State
Zip
County
State Issue
State
Zip
County
I hereby authorize the release to Blueline Services, an independent background screening agency, any information regarding my prior
employment, criminal, credit, driving, workers compensation, and educational history; as well as, information
regarding my general character and reputation. I understand the information may be reviewed initially and periodically during the course of
my employment for future screening for retention, promotion, or reassignment.
I understand that my background may be used to determine my eligibility for employment, and I agree that falsification may make me
ineligible for e