Background Check Disclosure And Authorization Form (Page 2 of 2) in pdf

I agree the Company may rely on this authorization to order background reports, including investigative consumer reports,

from companies other than ADP Screening and Selection Services without asking me for my authorization again as

allowed by law. I also agree that a copy of this form is valid like the signed original. I certify that all of the personal

information I provided is true and correct.

Please print your legal name:

(Month/Day/Year)______/_______/________

Last Name ____________________________First ___________________________ Middle ______________

Signature __________________________________________________________ Date: ___/___/___

BACKGROUND CHECK INFORMATION:

The information requested below is collected solely for the purpose of aiding the Company in running a background check

in connection with your application for employment. The employer is requesting that you provide this information to assist

in conducting a thorough background check.

First Name ________________Middle Name __________________Last Name_________________________

Date of Birth ____/____/_______ (Month/Day/Year)

Social Security Number ____________________________________________________

Driver’s License Number ______________________________ State Issuing License_____________

Enter Nickname(s) Used_____________________________________________________________

Have ever been know by any other name(s) including your maiden name prior to marriage? Yes ______ No_______

If yes, Please print all previous names_______________________________________________________________

Addresses Within The Past Seven Years (use a separate sheet as needed)

Present Street Address ___________________________________________________________

City/State/ZIP ___________________________________________________________________________

From _____/_______/______ (Month/Day/Year)

To _____/_______/______ (Month/Day/Year)

Prior Street Address _________________________________________________________________

Prior City/State/ZIP ________________________________________________________________________

From _____/_______/______ (Month/Day/Year)

To _____/_______/______ (Month/Day/Year)

Have you ever been convicted of a misdemeanor? Yes ________ No __________

If yes, when and where?

Have you ever been convicted of a felony? Yes ________ No __________

If yes, when and where?

Have ever been know by any other name(s) including your maiden name prior to marriage? Yes ______ No_______

If yes, Please print all previous names_______________________________________________________________

Have you ever had a different Social Security number? Yes ________ No ________, If yes, What #_____-_____-______

NOTE: No applicant will be denied employment solely on the grounds of conviction of a criminal offense. The nature of the offense, the date of the

offense, the surrounding circumstances and the relevance of the offense to the position applied for may however be considered.

Background Check Disclosure And Authorization Form Page 2