Print Name:
| (First) | (Middle) | (Last) | |||||||
| Former Name(s) and Dates Used: | |||||||||
| Current Address Since: | |||||||||
| (Mo/Yr) | (Street) | (City) | (Zip/State) | ||||||
| Previous Address From: | |||||||||
| (Mo/Yr) | (Street) | (City) | (Zip/State) | ||||||
| Previous Address From: | |||||||||
| (Mo/Yr) | (Street) | (City) | (Zip/State) | ||||||
| Social Security Number: | Date of | ||||||||
| Birth: | |||||||||
Telephone Number:
Drivers License Number/State:
To my best knowledge, all of the information in this application is accurate. I thus provide permission to (Organization Name) and its designated agents and representatives to conduct a thorough investigation into my background, leading to the creation of a consumer report and/or an investigative consumer report for employment and/or volunteer purposes.
I am aware that the scope of a consumer report or investigative consumer report may cover the following topics, without being limited to them, social security number verification, current and previous addresses, employment history, educational background, and character references,
drug testing, civil and criminal history records from any criminal justice agency in any or all federal, state, or county jurisdictions, driving records, birth records, and any other public records.
I hereby absolve______________ (Organization Name), the Social Security Administration, and any of their officers, employees, representatives, or assigned agencies, as well as any related personnel, individually and collectively, from any and all liability for any damages of any kind that may, at any time, result to me, my heirs, family, or associates as a result of compliance with this authorization and request to release.
Signature: ______________________________________ Date: ______________