Authorization for Release of Personal and Employment Information

Authorization and Consent for Release of Personal and Employment Information

I, _____________________________________ consent and authorized __________________________________________ (name of your company) and it’s authorized agents, FYI Services, to conduct a pre-employment background search on me. You are hereby authorized and requested to reveal and to discuss with FYI Services, or it’s authorized representatives, any and all information you have concerning my employment history, credit history, criminal history, academic history, medical condition, driving record, personal habits, general demeanor, or any other information deemed pertinent to my background.

I further understand that an investigative consumer report concerning me may include information about my character, general reputation, personal characteristics and mode of living. Under Federal Trade commission, Fair Credit Reporting Act, and Federal and State Law, I am entitled to receive a free copy of any consumer report containing public information obtained directly by the employer; or all of the information obtained by the investigative reporting agency within three days of the time the report is release to the employer along with a copy of “Your Rights Under the Fair Credit Reporting Act.” State and Federal laws also require the employer to give me notice, if adverse action is take based upon the contents either wholly or partly because of information contained in an investigative consumer report, along with a copy of the investigative report. I understand I have the right to dispute directly with the consumer reporting agency any findings within any consumer/investigative report, if the dispute is made in writing by me within 60 days of the date of the adverse action.

I understand that the information you may release is personal and confidential so, I release you, the persons, individuals, companies, corporations and entities, as well as FYI Services from any liability for obtaining and providing any and all such information for the purpose of preparing this personal and/or employment background evaluation only.

I hereby waive any and all claims for damage or injury as a result of obtaining and providing this information as to FYI Services. I further agree to indemnify and hold harmless FYI Services and the individual and companies releasing this information for any and all claims, costs, damages, or injury, which may occur as a result of obtaining and providing such personal and confidential information. This authorization is to remain in effect during my entire employment if selected for employment.

I have read the foregoing and agree to be bound by the terms of this authorization and release.

PLEASE PRINT CLEARLY.

Full Legal Name: _______________________________________________________________________

Other Names Used: _____________________________________________________________________

Social Security Number: __________________________________________________________________

Date of Birth (for identification purposes only): ________________________________________________

Drivers License/Identification Number and State: ______________________________ State: ________

Current Address: ________________________________________________________________________

Previous Address (past seven years): _________________________________________________________

Telephone Number: _____________________________________________________________________

I have read this Authorization and Consent for Release of information and fully understand the terms of this release:

Signature: _______________________________________________ Date __________________________

___ I am a California resident and would like a free copy of my report mailed to the above current address.