SUBJECT RELEASE FOR APPLICANT USE

EMPLOYMENT


Please print [black ink only] or type information on this application
Enter name of prospective employer:
Last Name:
First Name:
Middle Name:
SSN#:	DOB:
City and State of Birth:
1. Driver's License Number and State:
2. Driver's License Number and State:

I hereby authorize your company or any agent of your company, to contact any of my previous employers or to contact schools, companies, credit bureaus, corporations, law enforcement agencies, persons and educational institutions to supply any and all information concerning my background. I hereby hold harmless your company and their agent from any and all liability and responsibility arising from their doing so. This research may be performed for information dating back for the past ten years.

I hereby do give your company and any agent of your company my permission, as a condition of employment for the release of any and all appropriate background information regarding my credit history, criminal history, driving record history or any and all other sources of information which is permissible by all governing laws pertaining to employment, insurance or credit history. I believe to the best of my knowledge that all information I have provided is accurate, true and correct and that I fully understand the terms of this release.

Signature:

Date:

Current:

Street Address - Apt. No. - City - State - County - Postal Code

Previous:

Street Address - Apt. No. - City - State - County - Postal Code

Phone:

(Area Code) Current home number

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Indemnity Release