In connection with my application for employment or proposed contract for services, I understand that investigative background inquiries are to be made on me that may include criminal, vehicle, credit and other reports. These reports may include information as to my character, work habits, performance and experience along with reasons for termination of past employment from previous employers. Further, I understand that you may be requesting information from various Federal, State, and other agencies which maintain records concerning my past activities related to my driving, criminal, civil and other experiences. Upon written request, additional information as to the nature and scope of these background checks will be provided.
I authorize without reservation, Diligent Data Service to furnish any of the above-mentioned information.
I understand that to aid in the proper identification of my file or records, the information requested below is required. This information will be used for identification only and will not, except as expressly job related, form the basis for an employment decision. Please include any previous addresses where you have resided over the last ten years.
Print Name ____________________________________________________________________
Soc Sec #: ______________________________ Date of Birth: ______________ Sex _________
Current Address (including county if known): _________________________________________
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Previous Address (including county if known):________________________________________
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Previous Address (including county if known):________________________________________
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Previous Address (including county if known):________________________________________
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Applicant's Signature: _______________________________________ Date: _______________