Employer and Applicant:             Do not attach this page to Employment Application.                            Version 05/22/04

Background Investigations and

 

Consumer Report / Investigative Consumer Report

(Including Substance-Abuse Testing / Drug Testing)

Disclosure and Release of Information Authorization

 

I authorize _____________________________ and Verifications, Inc., 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 identification purposes in verifying information on your Employment Application.  PLEASE PRINT CLEARLY.

 

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Last Name                                                                              First Name                          Middle Name                                        

 

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Street Address                                                                     City                                          State                                          ZIP

 

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Driver’s License Number                                 State of License                                 Expires On                           Date of Birth

 

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

 

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

 

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