AUTHORIZATION FORM FOR CONSUMER REPORTS
Order Number:___________
HR Use Only
In connection with my application for employment (including contract for services), I understand that
consumer reports or investigative consumer reports which may contain public record information may be
requested or made on me including criminal records. Further, I understand that information from various
Federal, State, local and other agencies which contain my past activities will be requested.
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.
Position: ________________________________________________________________
Department:______________________________________________________________
Print Your Full Legal Name__________________________________________________
Current Address ___________________________________________________________
City________________ County ________________ State______ ZIP___________
Date First Resided at this Address
(Month & Year) _________________________________________
Social Security Number__________________________
Drivers License State ___________ License number_______________________________
For identification purposes
Date of Birth: Month______ Day_______ Year ________ Race______ Gender: M F
Other or former names_______________________________________________________
Signature______________________________________________ Date _______________
Previous Addresses in last 7 years
Must Include County and Dates (Month & Year)
1.________________________________________________________________________________
Street Address, City, County, State, Zip F
rom: To:
2.________________________________________________________________________________
Street Address, City, County, State, Zip F
rom: To:
3.________________________________________________________________________________
Street Address, City, County, State, Zip F
rom: To:
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