Criminal History Report Procurement Authorization Template
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1Criminal History Report Procurement Authorization
For Company Use Only
Murphy and Associates
Company:
Date:_____________
Co. Representative: Erik Murphy
Company Representative Contact Number: (425) 250-1300
Applicant Name
:_____________________________
_______________________________ ___________________
(Last)
(First)
(Middle Name)
(Please print clearly)
Applicant Maiden Name/Alias (list all): _________________________________________________________
Social Security
Drivers License
State
#________-_______-____________
#_________________________
______
Date of Birth
Place of Birth
: _______--_________--_________
____________________________
(Month)
(Day)
(Year)
____________
_________
____________
_____________
____________
___________
Height
Weight
Hair color
Eye color
Race
Sex(M/F)
Have you been convicted or accused of a felony?
If yes, please give:
_____ Yes
______ No
Please note: Admittance of felony convictions does not automatically disqualify employment.
___________
______________
__________
__________________________
DATE
COUNTY
STATE
CRIME
Current Phone/Pager
Current Street Address
City
State
County
(_____)____________ ______________________________ _______________________ __________ _________
List below addresses at which you have lived in the past seven years, with dates.
From
To
Previous Street Address
City
State
County
________ ________ ______________________________ _______________________ __________ _________
________ ________ ______________________________ _______________________ __________ _________
________ ________ ______________________________ _______________________ __________ _________
The undersigned, in connection with an application for employment, hereby authorizes the procurement of an investigative report. This authorizes
any law enforcement or judicial agency, corporation, company or others to provide relevant information they may have on the applicant to
Background Checks, Inc. This further releases all parties providing information from any and all liabilities or responsibility for doing so. The
undersigned hereby acknowledges that they read or have had read to them this authorization and they understand it. A copy of this authorization has
the same authority as the original.
______________________________________________________
_____________________________________
Signature
Date
Form last revised 1/03
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