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Background Check Authorization Form

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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