Release Authorization And Fair Credit Reporting Act Disclosure Form Page 2

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INFORMATION FOR PROCESSING OF BACKGROUND SCREEN REPORTS ONLY
(to be used for no other purposes)
Full Name _________________________________________________________________________________________
Social Security #: ________-________-_________
Date of Birth: _____/______/________
Current Residence Address: ___________________________________________________________________________
(Number & Street)
City
State
Zip
List all Residence Addresses in Past Seven Years (attach additional sheets if necessary)
_____________________
___________________________________________________________________________
(Date from – to )
Number & Street)
City
State
Zip
_____________________
___________________________________________________________________________
(Date from – to )
Number & Street)
City
State
Zip
_____________________
___________________________________________________________________________
(Date from – to
Number & Street)
City
State
Zip
_____________________
___________________________________________________________________________
(Date from – to )
(Number & Street)
City
State
Zip
Driver’s License Number ___________________________ State Issued _______________________________________
PLEASE SUPPY THE FOLLOWING SCHOOL INFORMATION (HIGHEST DEGREE EARNED): N/A
SCHOOL: ____________________________________________________ CITY/STATE: ______________________
DEGREE: ___________________________________________ DEGREE STATUS: ___________________________
DATES ATTENDED: _______________________________________________________________________________
(Start Month / Year)
(End Month / Year)
Rev. 1.24.07

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