Combined Disclosure Notice And Authorization Consumer Reports Form (Page 2 of 2) in pdf

Combined Disclosure Notice And Authorization Consumer Reports Form Page 2

AUTHORIZATION

By signing below, you hereby authorize without reservation, any party or agency contacted by

this employer to furnish the above mentioned information. You further authorize ongoing

procurement of the above mentioned reports at any time during your employment (or contract).

You also agree that a fax or photocopy of this authorization with your signature be accepted with

the same authority as the original.

You hereby authorize and request, without any reservation, any present or former employer,

school, police department, financial institution, division of motor vehicles, consumer reporting

agencies, or other persons or agencies having knowledge about you to furnish First Advantage

with any and all background information in their possession regarding you, in order that your

employment qualifications may be evaluated.

Print your Name: ______________________________________________________

Street Address: ________________________________________________________

City: ______________________________ State: ___________ Zip: _____________

Social Security Number: ________________________________________________

Driver’s License State: _________ License Number: _________________________

The following is for identification purposes only to perform the background check:

Date of Birth (MM/DD/YYYY): ____________ Race: ____ Gender (M or F): _____

Other or Former Names: _________________________________________________

Professional License: ______ State: _______ Type: _______ Number: ____________

Signature: ____________________________________ Date: _____________________

Combined Disclosure Notice And Authorization Consumer Reports Form Page 2