Consumer Report Form / Investigative Consumer Report Form (Including Substance-Abuse Testing / Drug Testing) Disclosure And Release Of Information Authorization Form printable pdf download

Employer and Applicant:

Do not attach this page to Employment Application.

Version 05/22/04

Background Investigations and

Substance Abuse Testing

Consumer Report / Investigative Consumer Report

(Including Substance-Abuse Testing / Drug Testing)

Disclosure and Release of Information Authorization

Vantage Point Solutions

Verifications, Inc.,

I authorize

and

a consumer-reporting agency, to retrieve information from all

personnel, educational institutions, government agencies, companies, corporations, credit reporting agencies, law enforcement

agencies at the federal, state or county level, relating to my past activities; and I authorize these entities to supply any and all

information concerning my background. The information received may include, but is not limited to, academic, residential,

achievement, job performance, attendance, litigation, personal history, credit reports, driving records, and criminal history records. I

understand some or all of this information may be transmitted electronically and authorize such transmission.

I understand substance-abuse testing/drug testing may be a requirement of the position for which I am applying, or the position I wish

to retain. I consent to this testing and understand I must pass the substance abuse test/drug test as a condition of employment or

continued employment.

I hereby authorize any physician, laboratory, hospital or medical professional to conduct such testing and

release the results to authorized representative/s of the above-named company and/or Verifications, Inc. I understand only test

results will be provided and no other medical information about me will be disclosed to anyone. I understand some or all of this

information may be transmitted electronically and authorize such transmission.

I understand a Consumer Report or Investigative Consumer Report (“Consumer Report”) may be prepared summarizing this

information. If my prior employers and/or references are contacted, the report may include information obtained through personal

interviews regarding my character, general reputation, personal characteristics, and mode of living.

Further, I understand the

Consumer Report may include substance-abuse testing/drug testing results. I may request a copy of any report that is prepared

regarding me and may also request the nature and substance of all information about me contained in the files of the consumer-

reporting agency. I understand I have the right to inspect those files with reasonable notice during regular business hours and I may

be accompanied by one other person. The consumer-reporting agency is required to provide someone to explain the contents of my

file. I understand proper identification will be required and I should direct my request to: Verifications, Inc., 1425 Mickelson Drive,

Watertown, SD 57201. Phone 1-800-247-0717 / 605-884-1200

If currently employed:

My current employer may be contacted.

_____ YES _____ NO

_____ N/A _____ Post Hire Only _____ Applicant's Initials

Is employment/prospective employment in California?

____ YES ____ NO

If you are applying for employment in the State of California please note that a new Disclosure and Release of information

Authorization is required for any subsequent Consumer Report/Investigative Consumer Report.

Are you applying for employment in California, Minnesota or Oklahoma?

____ YES ____ NO

If so, would you like a copy of any Consumer Report prepared on you?

____ YES ____ NO

I hereby certify all the statements and answers set forth on the application form and/or my resume are true and complete to the best

of my knowledge, and I understand that if subsequent to employment any such statements and/or answers are found false or

information has been omitted, such false statements or omissions will be just cause for the termination of my employment. Further, I

understand that by requesting this information, no promise of employment is being made. I am willing that a photocopy of this

authorization be accepted with the same authority as the original; and that if employed by the above-named company (except if

employed in the state of California), this authorization will remain in effect throughout such employment.

____________________________________

_______________________________

___________________________

Signature

Social Security Number

Date

NOTE: The following information is provided voluntarily and IS NOT considered as part of your application. It is used only for

. PLEASE PRINT CLEARLY.

identification purposes in verifying information on your Employment Application

__________________________________________________________________________________________________________

Last Name

First Name

Middle Name

__________________________________________________________________________________________________________

Street Address

City

State

ZIP

__________________________________________________________________________________________________________

Driver’s License Number

State of License

Expires On

Date of Birth

__________________________________________________________________________________________________________

List any other CITIES AND STATES in which you have lived during the previous 7 years.

__________________________________________________________________________________________________________

List any other LAST NAMES you have used during the previous 7 years.

__________________________________________________________________________________________________________

List any other LAST NAMES under which you received your GED, high school diploma, or other degrees.

Consumer Report Form / Investigative Consumer Report Form (Including Substance-Abuse Testing / Drug Testing) Disclosure And Release Of Information Authorization Form

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