Recruitment Survey Template - City Of Fairfield Page 2
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1
2TO:
PERSONNEL
RE:
APPLICANT BACKGROUND VERIFICATION
AUTHORITY TO RELEASE INFORMATION
FULL NAME:
__________________________________________________________________
Signature
FULL NAME:
__________________________________________________________________
Type or Print
Parent or Guardian:
__________________________________________________________________
(If applicable)
Date:
__________________________________________________________________
Current Address:
__________________________________________________________________
__________________________________________________________________
Telephone Number:
__________________________________________________________________
Social Security #:
__________________________________________________________________
Driver’s License #:
__________________________________________________________________
Date of Birth:
__________________________________________________________________
Position Applied For:
__________________________________________________________________
________________________________________________________________________________________
DO NOT WRITE BELOW THIS LINE
FOR OFFICIAL USE ONLY
Criminal History:
[] YES [] NO
If yes, please comment:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
________________________________________________________________
Driving History:
Valid Operator's License:
[] YES [] NO
Restrictions:
[] YES [] NO
Points: __________
______________________________________________________________________
Signature of person completing this background check.
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Parent category: Legal