Authorization For Release Of Information printable pdf download

AUTHORIZATION FOR RELEASE OF INFORMATION

To: Any registrar, dean, principal, or other authorized person or school (university, college, high school, vocational school, or other);

any former employer; any law enforcement agency; any department or agency of a city, county, state or federal government; any person

having knowledge of my conduct or activities; or any concerned credit bureau.

I hereby authorize PFC Information Services, or authorized representative bearing this release or copy thereof, and the requester listed

below to conduct a background check including, but not limited to, educational records, workers’ compensation records, court

documents or other public records, driving records, criminal records, or employment records. I authorize all persons who may have

information relevant to this check to disclose this information to PFC Information Services, or its agent, and I hereby release all persons

from liability on account of such disclosure. This release shall remain in effect for the future preparation of consumer reports, unless I

revoke this authorization in writing and send a copy of the revocation to PFC Information Services, Inc. I hereby further authorize that

a photocopy or fax of this authorization can be considered as valid as an original. Should there be any questions as to the validity of this

release, I can be contacted as indicated below.

THIS SECTION IS TO BE COMPLETED BY THE APPLICANT

SIGNATURE OF APPLICANT _________________________________________________________________________________

(Date)

NAME ON DRIVER’S LICENSE ______________________________________________________________________________

(First)

(Middle)

(Last)

PERMANENT ADDRESS _____________________________________________________________________________________

(Street)

(City)

(County)

(State)

(Zip)

PLEASE TELL US ABOUT OTHER NAMES & ADDRESS USED DURING LAST 10 YEARS:

____________________________________________________ _________________________________ ____________________

(City)

(State)

(Zip)

(Name Used)

(Dates)

DATE OF BIRTH: _________/_________/_________

SOCIAL SECURITY # _______-_______-________

(Month/Day/Year)

DRIVER'S LICENSE (DL) # __________________________________________

DL ISSUING STATE ____________________

Note: Signature of applicant constitutes acknowledgement by the applicant that he/she is aware that an investigative report and/or consumer report

may be ordered. The applicant may request a copy of the investigative and/or consumer report by checking the following box. □

Please NEATLY provide your email/mailing address if a copy is desired:

PFC Information Services, Inc. at 6114 La Salle Ave., #638, Oakland, CA 94611. Phone: 510.336.9761

THIS SECTION IS TO BE COMPLETED BY THE REQUESTER OF THE REPORT

REQUESTER OF REPORT ___________________________________

EMAIL_______________________________________

PLEASE PRINT CLEARLY: APPLICANT’S Date of Birth, Social Security Number, and Driver’s License #

_______ /______/_________

_______-_______-___________

________________________________

(Date of Birth – Month/Day/Year)

(SSN)

(DMV #)



7-Year Criminal Check



Social Security Number Verification



Driving Record



National Wants & Warrants



National Criminal File



National Sex Offender Registry



Civil Protective Orders (Current and/or Permanent Location)

Name(s) for Criminal Checks (City/State)

Location(s) for Criminal Checks (City/State)

_______________________________________________________________

______________________________________________________________________

_______________________________________________________________

______________________________________________________________________

_______________________________________________________________

______________________________________________________________________

Authorization For Release Of Information

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