REQUEST, AUTHORIZATION, CONSENT AND RELEASE FOR
BACKGROUND INFORMATION
PLEASE TYPE OR PRINT
I: _______________________________________________________________________________________________
LAST NAME FIRST NAME MIDDLE NAME (PLEASE INCLUDE Jr., Sr., II, III Etc.)
Understand that in conjunction with my application for license, the
CITY OF WOODSTOCK-VENDOR/PEDDLER LICENSE
PROGRAM
will use the services of an outside agency to research and verify the information I have provided on my application
for license including my personal background, character, professional standing, work history and qualifications. This agency will
provide a report to the
CITY OF WOODSTOCK-VENDOR/PEDDLER LICENSE PROGRAM. The CITY OF
WOODSTOCK-VENDOR/PEDDLER LICENSE PROGRAM
uses Backgrounds Online, a consumer-reporting agency, as an
agent to perform background verifications.
Backgrounds Online will utilize various sources of information it deems appropriate including but not limited to: credit reporting
agencies, Workers Compensation records, Department of Motor Vehicle records, criminal conviction records, current and former
employers, military records, education records, professional and personal references. I request, authorize and consent to the
release and disclosure of any and all information including but not limited to the above to the
CITY OF WOODSTOCK-
VENDOR/PEDDLER LICENSE PROGRAM
and Backgrounds Online.
I request, authorize and consent to the procurement of an Investigative Consumer Report and understand that it may contain
information about my background, mode of living, character, personal characteristics and general reputation. This authorization
in original or copy form shall be valid for one year from the date indicated next to my signature. According to the Fair Credit
Reporting Act, I will be notified by the
CITY OF WOODSTOCK-VENDOR/PEDDLER LICENSE PROGRAM if licensure is
denied because of information obtained from a Consumer Reporting Agency. Additionally, I understand that if requested within
60 days, I will be given a full and accurate disclosure as to the nature and substance of all information provided to the
CITY OF
WOODSTOCK-VENDOR/PEDDLER LICENSE PROGRAM.
I further understand that when requesting a copy of the report,
proper identification will be required and I should direct my request to: Backgrounds Online, 1915 21
ST
Street, Sacramento, CA
95811, phone: 800-838-4804. Backgrounds Online’s website may be found at http://www.backgroundsonline.com
LAW ENFORCEMENT AGENCIES AND OTHER ENTITIES FOR POSITIVE IDENTIFICATION PURPOSES REQUIRE THE
FOLLOWING INFORMATION WHEN CHECKING PUBLIC RECORDS. IT IS CONFIDENTIAL AND WILL NOT BE USED FOR ANY
OTHER PURPOSES. I HEREBY RELEASE THE
CITY OF WOODSTOCK-VENDOR/PEDDLER LICENSE PROGRAM AND
ITS AGENTS, BACKGROUNDS ONLINE AND ALL PERSONS, AGENCIES, AND ENTITIES PROVIDING INFORMATION OR
REPORTS ABOUT ME FROM ANY AND ALL LIABILITY ARISING OUT OF THE REQUEST FOR OR RELEASE OF ANY OF THE
ABOVE MENTIONED INFORMATION OR REPORTS.
__________ __________
Signed Today’s Date
__________
__________
Printed Name License Applied For
_______---_____---________ ____/_____/____ ________________
Social Security Number Date of Birth Driver’s License Number State
Other names you have used or are also known as: ________________________
PLEASE PROVIDE ALL RESIDENTIAL ADDRESSES FOR THE PAST 7 YEARS
Current Address: _________________________________________________________________________________________________________
Street Apt.# City County State Zip Code How long here?
Current Address: _________________________________________________________________________________________________________
Street Apt.# City County State Zip Code How long here?
Current Address: _________________________________________________________________________________________________________
Street Apt.# City County State Zip Code How long here?
Current Address: _________________________________________________________________________________________________________
Street Apt.# City County State Zip Code How long here?
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No
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