Background Check

Full Name (First Middle Last)

Email

Phone

Other Names Used

Address

County

Date of Birth

SSN

Driver's License #

State Issued

Position Applied For

Please indicate if you are a member of a volunteer organization

Gender

Male Female

I hereby authorize VERIFYI and or its Service Provider to request and receive any and all background information about or concerning me, including but not limited to my Criminal History, Social Security Number Trace including a consumer report under the Fair Credit Reporting Act, 15 U.S.C 1681, Driving Record, Employment History, Military Background, Civil Listings, Educational Background, Professional License from any Individual, Corporation, Partnership, Law Enforcement Agency, and other entities including my Present and Past Employers.

The criminal history, as received from the reporting agencies, may include arrest and conviction data as well as plea bargains and deferred adjudications and delinquent conduct as committed as a juvenile. I understand that this information will be used, in part, to determine my eligibility for an employment/volunteer position with this organization. I also understand that as long as I remain an employee or volunteer here, the criminal history check may be repeated at any time. I understand that I will have an opportunity to review the criminal history as received by client/agency and a procedure is available for clarification, if I dispute the record as received. I also understand that the criminal history could contain information presumed to be expunged.

I further release and discharge VERIFYI and their Service Provider and all of their Subsidiaries, Affiliates, Officers, Employees, Contract Personnel, or Associates, from any and all claims and liability arising out of any request for information or records pursuant to this authorization, procurement of an investigative consumer report and understand that it may contain information about my character, general reputation, personal characteristics, and mode of living, whichever are applicable.

I understand that I have the right to make written request within a reasonable period of time to VERIFYI for additional information concerning the nature and scope of the investigation. I acknowledge that I have voluntarily provided the above information for employment/volunteer purposes, and I have carefully read and understand this authorization.

By entering your digital signature below you agree to the above terms of authorization:

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