BONNEVILLE COUNTY IS AN EQUAL OPPORTUNITY EMPLOYER
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BACKGROUND INVESTIGATION FORM
The following information is required to conduct a background investigation and will not be considered directly in
determining your qualifications or suitability for employment.
FULL LEGAL NAME (Last, First, Middle)
SOCIAL SECURITY NUMBER
CURRENT STREET ADDRESS
DATE OF BIRTH
LIST ALIASES, NICKNAMES, MAIDEN NAMES AND OTHER NAMES BY WHICH YOU ARE OR HAVE BEEN KNOWN:
SEX: MALE FEMALE
RACE OR ETHNIC ORIGIN:
HEIGHT:
WEIGHT:
EYE COLOR:
HAIR COLOR:
PREVIOUS RESIDENCES FOR THE PAST TEN YEARS
DATES: ADDRESS:
DATES: ADDRESS:
DATES:
ADDRESS:
DATES:
ADDRESS:
DATES:
ADDRESS:
FAMILY AND OTHER HOUSEHOLD MEMBERS
RELATIONSHIP AND NAME
TELEPHONE
FATHER
MOTHER
BROTHERS &
SISTERS
BONNEVILLE COUNTY IS AN EQUAL OPPORTUNITY EMPLOYER
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FAMILY AND OTHER HOUSEHOLD MEMBERS (Cont'd)
RELATIONSHIP AND NAME
TELEPHONE
SPOUSE
CHILDREN
OTHER
FORMER MARRIAGES
SPOUSES NAME AND ADDRESS
DIVORCE DATE
FRIENDS AND SOCIAL ACQUAINTANCES
NAME
CURRENT ADDRESS
TELEPHONE
(ATTACH ADDITIONAL SHEETS IF NECESSARY)
BONNEVILLE COUNTY IS AN EQUAL OPPORTUNITY EMPLOYER
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BONNEVILLE COUNTY
605 N. CAPITAL AVE., IDAHO FALLS, ID 83402
AUTHORIZATION FOR RELEASE OF INFORMATION
I the undersigned, hereby authorize Bonneville County to investigate any and all information which may
be necessary to determine my qualifications for employment including records subject to the Privacy
Act of 1974 (Public Law 93-579).
I understand that this investigation may include employment, education, driving, military, medical,
credit, police, civil and criminal records. I also understand that I have a right to make a written request
within a reasonable time to receive information about the nature and scope of such investigation.
The release of any and all factual information is authorized whether of record or not and I do hereby
release all persons, organizations, firms, agencies, companies or groups from any damages resulting
from furnishing such information to Bonneville County. I also agree that a copy of this release shall
function as an original.
NAME:____________________________________ Soc. Sec. No. _____________________
(Print or Type)
Signature ____________________________________________________
Date ______________________________
click to sign
signature
click to edit
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