Background Tenant Screening Information Form

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Background Screening Information Form
Basic Information
Legal First Name
Legal Middle Name
Legal Last Name
Maiden and/or Other Last Name Used
Email Address
Date of Birth
Social Security Number
Current Physical Address (no P.O. Boxes)
City
State
Zip
The following are my responses to questions about my criminal record history (if any) with descriptions to any
question with a YES answer:
1. Have you ever been convicted or plead guilty before a court of any federal, state, or municipal criminal offense?
(Excluding minor traffic violations) YES NO If YES, please provide an explanation below:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
2. Have you ever received deferred adjudication or similar disposition for any federal, state or municipal criminal
offense? YES NO If YES, Please provide an explanation below:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
3. Have you ever received probation or community supervision for any federal, state or municipal criminal offense?
YES NO If YES, Please provide an explanation below:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
4. Have you ever been arrested for molesting or abusing a minor? YES NO If YES, please provide an explanation
below:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
5. Have you ever been convicted of any criminal offense in a country outside the jurisdiction of the United States?
YES NO If YES, Please provide an explanation below:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
6. As of the date of this authorization, do you have any pending criminal charges against you? YES NO If YES,
Please provide an explanation below:
_____________________________________________________________________________________________
____________________________________________________________________________________________
7. As of the date of this authorization, have you ever been evicted? YES NO If YES, Please provide an explanation
below:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Background Screening by C4 Operations, Inc. | 1-888-519-6283 |
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