Background Information Release
In connection with my application for employment (including contract for services), I understand that consumer
or investigative consumer reports which may contain public record information, may be requested or made on me
including consumer credit, criminal records, driving record, education, prior employer verification, workers
compensation claims and others. These reports will include experience along with reasons for termination for past
employment. Further, I understand that you will be requesting information from various Federal, State and Local
agencies regarding my past activities. I also understand that the information below regarding sex, race and date of
birth is requested for the sole purpose of gathering the above information correctly, and will not be used to
discriminate against me in violation of any law.
I hereby authorize without reservation, any party or agency to furnish the above-mentioned information.
FOR IDENTIFICATION PURPOSES: PLEASE PRINT ALL INFORMATION CLEARLY
(Name)
Last:________________________________________ First:______________________________________
Middle:__________________ Other Names Maiden, Aliases, etc.__________________________________
Date of Birth: Month:____ Day :____ Year: _______ Race: ____ Gender:____ Phone:__________________
Social Security # ________-________-________ Drivers License # ___________________ State: ________
LIST ALL ADDRESSES FOR THE PAST SEVEN (7) YEARS STARTING WITH THE MOST CURRENT:
Street
City
State
Zip
Dates (MM/YEAR)
1.
From:_____To:_____
2.
From:_____To:_____
3.
From:_____To:_____
4.
From:_____To:_____
5.
From:_____To:_____
Signature
Date
:_________________________________________________________________
:_________________
Employee
Volunteer Coach
Substitute
Non-Employee Contractor Coach
Volunteer
Chaperone
Other: