AUTHORIZATION FORM FOR CRIMINAL RECORDS REPORTS (for P-Card renewals)
Order Number______________
HR Use Only
In connection with my P-Card renewal, I understand that a background check which may contain public record
information may be requested on me including criminal records. This process will be performed to ensure that
my background is checked prior to the next renewal date of the individual P- Card. Further, I understand that
information from various Federal, State, local and other agencies which contain my past activities will be
requested.
Consumer (credit) reports will not be requested for P-Card renewals.
By signing below, I hereby authorize, without reservation, any party or agency contacted by this employer to
furnish the above mentioned information. I further authorize ongoing procurement of the above mentioned
reports at any time during my employment (or contract). I also agree that a fax or photocopy of this
authorization with my signature can be accepted with the same authority as the original.
Print your name _______________________________________________________________________
Department _______________________________________________________________________
Current address ________________________________________________________________________
City ___________________________ County ____________________ State __________ ZIP ________
Date first resided at this address (month & year) _______________________________________________
Social Security Number __________________________________________________________________
Driver’s license state ____________________ License number ___________________________________
For Identification Purposes
Date of Birth: Month_______ Day _______Year _____ Race _________ Gender: Male Female
Other former names ______________________________________________________________________
Signature __________________________________________________________ Date ________________
Previous Addresses in Last 7 Years
Must Include County and Dates (Month & Year)
1. ____________________________________________________________________________________
Street Address, City, County, State, Zip From: To:
2. ____________________________________________________________________________________
Street Address, City, County, State, Zip From: To:
Use Reverse Side if Necessary
