The background check authorization form is permission by an individual to another, a company, employer or other entities to investigate his or her past records and incidents or accidents on record. This is a voluntary form and the person may assent to or deny the party permission to conduct the check.
BACKGROUND CHECK AUTHORIZATION FORM
(This form is to be filled by the individual whose background is to be checked)
First Name: ___________________ Middle Name: _____________ Last Name __________
Other name(s) that may have been used in the past _______________________________
Gender __________ Date of Birth: ________________ Place of birth _________________
State / province __________________ Country ________________________________
Social Security Number: _________________________ Nationality ___________________
Phone: _________________________________ Email: ____________________________
Address: ________________________________ Town: ____________________________
Zip: ______________________________ State: ____________________________
Do you have any criminal convictions? __________
If YES, briefly explain the nature _______________________________________________
_________________________________________________________________________
Country, state and county that the conviction occurred ______________ Date __________
I hereby give permission to ____________________________________ to run a background check on the information provided in this form.
Signature _____________________________ Date _____________________________
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