REQUEST, AUTHORIZATION, CONSENT AND RELEASE FOR BACKGROUND INFORMATION

 

PLEASE TYPE OR PRINT

 

I:                                                                                                                                                                                 

     LAST NAME                                       FIRST NAME                                            MIDDLE NAME                         (PLEASE INCLUDE Jr., Sr., II, III Etc.)

 

Understand that in conjunction with my application for employment, USA Chess, Inc will use the services of an outside agency to research and verify the information I have provided on my application for employment including my personal background, character, professional standing, work history and qualifications. This agency will provide a written report of its findings to USA Chess, Inc.  USA Chess, Inc uses AbsoluteBackgrounds.com, a consumer-reporting agency, as an agent to perform its employment related background investigations.

 

AbsoluteBackgrounds.com will utilize various sources of information it deems appropriate including but not limited to: credit reporting agencies, workers Compensation records including any and all injuries in compliance with the Federal ADA Act, Department of Motor Vehicle records, criminal conviction records, current and former employers, military records, education records, professional and personal references. I request, authorize and consent to the release and disclosure of any and all information including but not limited to the above to USA Chess, Inc, and AbsoluteBackgrounds.com.

 

I request, authorize and consent to the procurement of an Investigative Consumer Report and/or Consumer Credit Report and understand that they may contain information about my background, mode of living, character, personal characteristics and general reputation. This authorization in original or copy form shall be valid for one year from the date indicated next to my signature. According to the Fair Credit Reporting Act, I will be notified by USA Chess, Inc if employment is denied because of information obtained from a Consumer Reporting Agency. Additionally, I understand that if requested within 60 days, I will be given a full and accurate disclosure as to the nature and substance of all information provided to USA Chess, Inc. I further understand that when requesting a copy of the report, proper identification will be required and I should direct my request to: AbsoluteBackgrounds.com, 104 Church Street, Roseville, CA 95678.

 

 

        CHECK THIS BOX IF you are applying for work with a California employer and you would like a copy of your

 

        Consumer Credit Report if one is included in the investigation of your background.  CA Civil Code § 1785.20.5

 

 

 

Law enforcement agencies and other entities for positive identification purposes require the following information when checking public records. It is confidential and will not be used for any other purposes. I hereby release USA Chess, Inc and its agents, AbsoluteBackgrounds.com and all persons, agencies, and entities providing information or reports about me from any and all liability arising out of the request for or release of any of the above-mentioned information or reports.

 

 

                                                                                                                                                                                                               

Signed                                                                         Today’s Date

 

                                                                                                                                                           

Printed Name                                                              Position Applied For

 

__      _—   —______       ____/_____/____                                                                                       

 Social Security Number         Date of Birth                 Driver’s License Number                      State

 

Other names you have used or are also known as:                                                                                                    

 

 

PLEASE PROVIDE ALL RESIDENTIAL ADDRESSES FOR THE PAST 7 YEARS

                                                                                                                                                           Mo./Yr. / Mo./Yr

 

Current Address:                                                                                                                                              /          

                              Street                     Apt.#                            City                  State         Zip Code         From / To?

 

Former Address:                                                                                                                                              /          

                              Street                     Apt.#                                        City                  State         Zip Code        From / To?

 

Former Address:                                                                                                                                              /          

                              Street                     Apt.#                                        City                   State         Zip Code       From / To?

 

Former Address:                                                                                                                                              /          

                             Street                      Apt.#                                        City                   State         Zip Code       From / To?