EmailMe Form - Background Check for Employment

RELEASE FORM FOR BACKGROUND CHECK

I, the undersigned, understand that investigative background inquiries are to be made on myself including consumer, criminal, driving and other reports. These reports will 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 will be requesting information from various Federal, State and other activities relating to my driving, credit, criminal, civil, and other experiences as well as claims involving me in the files of insurance companies.

I authorize, without reservation, any party or agency contacted by East Wake Academy to furnish the above-mentioned information.

A photocopy, or any other copy, of this instrument bearing my signature shall be equally legally valid as the original.

Name *

First Last

Maiden Name or AKA

Dates used from:

MM / DD / YYYY

Dates used to:

MM / DD / YYYY

Social Security Number *

Date of Birth *

MM / DD / YYYY

** Date of Birth is being requested in order to obtain accurate retrieval records.

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country

Drivers Licence Number *

State Licence Issued

Please list all address you have lived at for the past ten (10) years. Include the year you moved to this address and the year you moved out.

Signature of Applicant *

Date *

MM / DD / YYYY

Witness Name *

First Last