AUTHORIZATION FORM FOR CONSUMER REPORTS
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 consumer credit, criminal records,
driving record, education, prior employer verification, workers
compensation claims and others. These reports will include experience
along with reasons for termination of past employment. Further,
understand that information from various Federal, State, local and other
agencies which contain your past activities will be requested.
By signing below, you hereby authorize without reservation, any party
or agency contacted by this employer to furnish the above mentioned
information. You further authorize ongoing procurement of the above
mentioned reports at any time during your employment (or contract). You
also agree that a fax or photocopy of this authorization with your
signature be accepted with the same authority as the original.
I have the right to make a request of INTELLICHOICE, INC., upon
proper identification and the payment of any authorized fees, for the
information in its files on me at the time of my request.
For California applicants only, if you would like to receive a
copy of the credit report, if one is obtained, please check this box.
For Minnesota or Oklahoma applicants only, if you would
like to receive a
copy of the consumer report, if one is obtained, please check this
box.
Print your name
_________________________________________________________
Current Address
_________________________________________________________
City________________________________________ State____
ZIP_____________
Social Security Number_____________________
Drivers License State ____ License
number_______________________________
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For identification purposes
Date of Birth Month____ Day_____ Year ____ Race____ Gender M F
Other or former
names____________________________________________________
Signature______________________________________________ Date
____________
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Previous Addresses in last 7 years
1.____________________________________________________________________
Street Address City State Zip
2._____________________________________________________________________
Street Address City State Zip
3._____________________________________________________________________
Street Address City State Zip