| The
information requested below is for the sole purpose of
conducting a background investigation which may include
a credit report, criminal records check, driving record,
and other reports. The information regarding age, sex,
or race will not be used as part of any hiring, promotion,
or termination decision.
Full
Name (no nicknames):________________________________ S.S.N.:_________________________
Other names previously used and when (maiden names, nicknames,
etc.):_________________________
Date
of Birth:________________ Driver's License Number:_____________________
State:_____
Have
you ever been convicted of a crime? Yes____ No____
If yes, give details:______________________________________________________________________
ADDRESS
Current:
_____________________________________________________________________________
_____________________________________________________________________________
Previous: _____________________________________________________________________________
_____________________________________________________________________________
Previous: _____________________________________________________________________________
_____________________________________________________________________________
EDUCATION
| Institution
|
Location |
Degree |
Dates
Attended |
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
I
_________________________ hereby authorize the recipient
of this release to search any of the following files which
the recipient possesses, and to release the contents of
those files to Executive Placement Associates and/or Employment
Information Service (EIS, Inc.):
1.
Federal, state, or county criminal history records
2. Financial History
3. Education records
4. Social Security Number Verification
I
authorize the reporting of the contents of any of the
above records to Executive Placement Associates or Employment
Information Service (EIS, Inc.). I release the recipient
of this release, the prospective employer named below
and Executive Placement Associates or Employment Information
Service (EIS, Inc.) from any and all liability for obtaining
and releasing such information.
Applicant
Signature:______________________________ Date: _____________
Prospective
Employer: _________________________________________________
FAX # (301) 287-8317
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