Background Check Form for Employment

Background Check
Authorization Form
Applicant Agreement and Release
I, the undersigned applicant, do hereby certify that all information provided by me for the purpose of employment is true and
complete to the best of my knowledge. I understand that falsification of any information on company documents may lead to denial of
employment or termination.
In connection with my application for employment, I understand that investigative background inquires will be made about
me that can include consumer credit, education verification, criminal convictions, motor vehicle records check, workers’
compensation, and others. These reports will include information as to my character, general reputation, work habits, performance,
and experience, along with reasons for termination of employment from previous employers. Further, I understand that you will be
requesting information from various federal, state, and other agencies that maintain records concerning my past activities relating to
my driving, credit, criminal, civil, and other experiences.
I authorize, without reservation, any party or agency contacted by Olson's Pest Technicians to furnish the above-
mentioned information prior to or at any time during my employment. The information on this form will be used solely
for the purpose of conducting background checks to determine employment eligibility and will be maintained in a
confidential file, separate from the general personnel file.
I hereby release all of the persons and agencies providing such information from any and all claims, damages, or
liabilities connected with their release of any requested information. I agree that any copy of this document is as valid as
the original.
I do hereby agree to forever release and discharge Olson's Pest Technicians to the full extent permitted by law
from any claims, damages, losses, liabilities, costs and expenses, or any other charge or complaint filed with any agency
arising from the retrieval and reporting of information. According to the Federal Fair Credit Reporting Act, I am entitled to
know if employment was denied based on information contained in a consumer credit report.
Applicant Information and Signature
I understand that to aid in the proper identification of my file or records, the following information is necessary:
Print Your Name ___________________________________________________________________________________
Current Address ___________________________________________________________________________________
Soc. Sec. No. ______________________ Date of Birth _____________________ Sex _______ Race _______________
Drivers’ License No. __________________________________________ State _________________________________
Applicant’s Signature _______________________________________________ Date __________________________
Applicant Request for Records
If the company obtains records from a consumer reporting agency, such as my credit report, (applicant, select one):
O I would like a copy O I would not like a copy
! The back of the form must be completed
Applicant Data for Background Checking Purposes
(Release from page 1 applies to this information)
1. What position are you applying for? _____________________________________________________________
2. Have you lived in any state(s) or countries other than the one you currently reside in?
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