Background Release Form - Sahara printable pdf download

Background Release Form - Disclosure and Consent

In connection with my application for employment (including contract for service) with Sahara

Management (“the Company”), I understand that investigative inquiries may be obtained on myself by a

consumer reporting agency, and that any such report will be used solely for employment-related

purposes. I understand that the nature and scope of this investigation will include a number of sources

including, but not limited to, consumer credit, criminal convictions, motor vehicle, and other reports.

These reports will include information as to my character, general reputation, personal characteristics,

mode of living, and work habits. Information relating to my performance and experience, along with

reasons for termination of past employment from previous employers, may also be obtained. Further, I

understand that you will be requesting information from various Federal, State, County and other

agencies that maintain records concerning my past activities relating to my driving, credit, criminal, civil,

education, and other experiences.

I understand that if the Company hires me, it may request a consumer report or an investigative

consumer report about me for employment-related purposes during the course of my employment. The

scope of this investigation will be the same as the scope of a pre-employment investigation, and that the

nature of such an investigation will be my continuing suitability for employment, or whether I possess the

minimum qualifications necessary for promotion or transfer to another position. I understand that my

consent will apply throughout my employment, unless I revoke or cancel my consent by sending a signed

letter or statement to the Company at any time, stating that I revoke my consent and no longer allow the

Company to obtain consumer or investigative consumer reports about me.

I understand that I am being given a copy of the “Summary of Your Rights Under the Fair Credit

Reporting Act” prepared pursuant to 15 U.S.C. Section 1681-1681u. If I am applying for employment in

the State of California or if I am a resident of California at the time of applying for employment, a

summary of the provisions of California Civil Code section 1786.22 is also being provided to me with this

form. This Disclosure and Consent form, in original, faxed, photocopied or electronic form, will be valid

for any reports that may be requested by the Company.

I authorize without reservation any party or agency acting on the behalf of this employer to furnish the

above-mentioned information. I hereby consent to your obtaining the above information from <<add

background seach firm name, address & telephone number>>. I understand to aid in the proper

identification of my file or records the following personal identifiers, as well as other information, is

necessary.

Print Name

________________________________________________________

Other Names Known By _______________________________________________

Social Security Number

_______-_____-________

Date of Birth ___/___/____

Driver License Number ______________________

State ___________________

Current Address

___________________________________________________

City

_____________________________________ State ______ ZIP _________

Applicant Signature _______________________________ Date_______________

SAHARA MANAGEMENT

Prospective Employer

California, Oklahoma or Minnesota Applicants:

I would like to receive a copy of any report obtained on me by “the Company”.

□ Yes

□ No

C:\dexform\good_results\data-new\266663.doc

Revised 2/2007

Background Release Form - Sahara

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