State: JURISDICTION_STATE

 BACKGROUND CHECK DISCLOSURE AND AUTHORIZATION FORM

Full Name: FULL_NAME
Former Names and Dates Used: FORMER_NAMES
Current Address: ADDRESS
Previous Address and Dates Resided: PREVIOUS_ADDRESS
Social Security Number: SSN	Date of Birth: DOB
Telephone Number: NUMBER
Driver Licence Number (State of Issuance): DRIVER_LICENCE

I hereby authorize ACCOUNT_JOB_COMPANY and its designated agents and representatives to conduct a comprehensive review of my background causing a consumer report and/or an investigative consumer report to be generated for the purpose of PURPOSE.  I understand that the scope of the consumer report/ investigative consumer report may include, but is not limited to the following areas: verification of social security number; current and previous residences; credit history; past and present employment and income; back accounts; credit reports; criminal history records from any criminal justice agency in any or all federal, state, county jurisdictions; driving records, birth records, and any other public records.               

I further authorize any individual, company, firm, corporation, or public agency to divulge any and all information, verbal or written, pertaining to me, to ACCOUNT_JOB_COMPANY­­­­­­­­­­­­­­­­­ or its agents.  I further authorize the complete release of any records or data pertaining to me which the individual, company, firm, corporation, or public agency may have, to include information or data received from other sources.

ACCOUNT_JOB_COMPANY and its designated agents and representatives shall maintain all information received from this authorization in a confidential manner in order to protect the applicants personal information, including, but not limited to, addresses, social security numbers, and dates of birth.

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