Ymca Of Metropolitan Los Angeles Application Form For Employment Page 5
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8AUTHORIZATION TO OBTAIN BACKGROUND INFORMATION
FOR EMPLOYMENT PURPOSES
(CAUTION: Please read carefully the contents of this notice before you sign it!)
I understand that in connection with the application process, the Association may request information from my
past employers, educational institutions, personal references, and any public or private agencies that have issued
me either a professional or vocational certification or license. I also understand that such investigation may
include a review of my credit history and any criminal records. In order to assist the Association in obtaining
documents and information to confirm my background, if necessary, I hereby consent to the release of information
more specifically described below.
Initial
I request, authorize and consent to the release of information to the Association regarding my previous employ-
ment and authorize all past employers or agents that they may designate, to respond to verbal or written
inquiries from the Association regarding my employment record, including, but not limited to, positions held,
dates of employment, last pay rate, work performance, disciplinary records, reliability, and any incidents of
dishonesty, insubordination, violence, and/or unsafe, harmful or threatening behavior, including information
based upon materials in my personnel files.
Initial
I request, authorize and consent to the Association's contacting the personal references identified in my application
for purposes of confirming information contained in my application for employment. I specifically request, autho-
rize and consent to the Association's verbal or written inquiries addressed to my personal references about the
information contained in my application, as well as my reliability, honesty and potential tendency, if any, to engage
in any form of violence or other harmful, unsafe or threatening behavior.
Initial
DATE: _____________________________________________________________________________________
NAME: _____________________________________________________________________________________
ADDRESS: __________________________________________________________________________________
––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––––
SIGNATURE: ________________________________________________________________________________
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