Employee Authorization to Release Records
I understand and agree that: The information supplied, was submitted by myself, and all information is true and correct, to the best of my knowledge. I understand that false or misleading information given in my application and/or interview(s) will be considered as cause for possible dismissal and/or discharge. I also understand that I am to abide by all rules and regulations of the company. The company has my authorization to thoroughly investigate my work and personal history. I understand that the information supplied by me, regarding my: Employment History, Education (including an authorization to release transcripts), Credit History, Criminal History, Medical and Professional Licensing, Motor Vehicle Record(s), Residence History, and References, will be utilized as part of the processing procedures. A background check will be conducted to verify the veracity of the information submitted and will be utilized to develop information concerning my character, general reputation, personal characteristics, and mode of living. I will hold no person liable for giving or receiving information in this investigation. I hereby authorize SentryLink LLC an agent of ______________________________ to make a thorough check of my past Employment, Education, and activities.
I release from liability all persons, companies, and corporations supplying that information.
I release and indemnify ______________________________ and SentryLink LLC against any liability that might result from making such background checks. A copy of this form is as valid as the original

EMPLOYEE/APPLICANT

 

___________________________
Last Name

 

____________________
First Name

 

______
Middle

 

_______-____-________
Social Security Number

 

_______/_______
Date of Birth mm/dd

 

_________________________________________________
Other Name(s) Maiden/Married

 

______________________________
Driver’s License Number

 

______________
State

RESIDENCES (Starting with current)

 

_________________________________________
Street Address

 

____________________________
City/State Zip

 

How Long?____

 

_________________________________________
Street Address

 

____________________________
City/State Zip

 

How Long?____

CURRENT EMPLOYER

CITY/STATE/ZIP

PHONE #

 POSITION

MAY WE CONTACT CURRENT EMPLOYER?

 

 

  

 


  

?? YES
?? NO

PREVIOUS EMPLOYER

CITY/STATE/ZIP

PHONE #

 POSITION

DATE OF EMP.

 

 

  

 


  


SCHOOL(S) ATTENDED NAME OF SCHOOL CITY/STATE DATES ATTENDED YEAR GRADUATED
High School     Not applicable Not applicable
College        
Other        


The following information is used for identification and statistical purposes. It is not used in any manner considered discriminatory under EEOC guidelines.

 

Date of Birth ____/____/______

 

Race ________

 

Sex ________

 

Telephone (____)______________________

 

Signature ________________________________________ Date Signed ______________________

Billing Information
This background check cost $20 to be billed to the following credit card information. This amount will be refunded to you when you have your first customer with us.

Billing Name
Card Number
   
Address
Card Expiration
   
City
Card CVV Code
   
State
(3 digit # on back)
   
Zip
 
   
           
Signature for Credit Card Billing __________________________________________________________      


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