Worker's Compensation Motor Vehicle

**

BACKGROUND INQUIRY RELEASE AUTHORIZATION

rerc,onnel olut,rbns The purpose of this release form is to notify you that a consumer report will be compiled in the course of consideration for your employment AND OR

,_.Lnc. continued employment.

I understand that, in connection with my application for or employment with Preferred Personnel, Inc., investigative background inquiries may be made on myself including, but not limited to consumer credit reports, criminal history information, motor vehicle records, previous employer verifications, education verifications, worker's compensation reports, and other reports. These Reports may include information as to my character, work habits, performance and experience, along with reason for termination of past employment. I further understand that the above mentioned employer, and/or it's authorized agent may be requesting information from various Federal, State, private, insurance, and other agencies concerning my past activities relating to my credit, driving, criminal, civil, and other experiences. I voluntarily and knowingly authorize each and every present and past employer or supervisor; college, university or other educational institution; finance bureau/office; credit bureau; collection agency; private business; personal reference; and other persons to give records of information they may have concerning my credit, criminal history, health, character, and employment, or any other information requested by the above mentioned employer or its authorized agent. I voluntarily, knowingly and unconditionally release any named or unnamed reporting party from any and all liability resulting from the furnishing of any information to either the employer or its authorized agent. I understand that if I am denied employment because of information that is found in the background investigation, I am entitled to a copy of the investigation report. The Company has made available to you "A Summary of Your Rights Under the Fair Credit Reporting Act." LEGAL Name (Last, First Middle) Date of Birth (m/d/y) __ / Maiden Name or "AKA" (Last, First Middle)_, Sex: __._Race _ Social Security Number Driver's License or State ID# State -- Exp. Date:. _ PROV IDE AL LAD D RE SSE s FOR PR EVIOUS

Street Address /List Current First)

1.

2.

3.

4.

5.

7 YEAR s . Ust vour current a d dress first

Act# Citv State, Zic

Have you EVER been convicted of a crime other than a minor traffic ticket Including? [NO IJYES (LIST DETAILS IF YESI Countv Dates Resided

TO

TO

TO

TO

TO

If you CHECKED YES AND have ever been convicted of a crime other than a minor traffic ticket, including any misdemeanor OR felony, please provide details to include Disposition of Conviction, Nature of the Crime, Conviction Date and State and County Convicted for ALL Convictions. You may use the back of this form if you need more room. Please note: Convictions of a crime will not necessarily be a bar to employment. Factors such as age at the time of offense, type of offense, remoteness of the offense In time, requirements of job and rehabilitation will be taken into account in determining the effect on suitability for employment. LIST ALL CONVICTIONS OTHER THAN MINOR TRAFFIC VIOLATIONS (use the back of this form if vou need more room I Felony or Date(s) of

Misdemeanor? Conviction(s) Conviction Time Served / Dates of Probation / Other Details Countv State I attest with my signature below that I have read and understand the authorization release above and I have given to Preferred Personnel, Inc. true and complete information. If any information that is proved is untrue or omitted, I understand that this/ these will constitute cause for denial of employment or immediate dismissal. I UNDERSTAND that there will be a $30 deduction for the cost of this background check from my paycheck. Printed Name Social Security Number

THIS SECTION FOR INTERNAL USE

Signature Date

Former Employer Contact Name Dates Employed _ As a former employer, we would appreciate any information you may provide to help us to determine a hiring decision. Any information provided will be kept in the employee's confidential personnel file. Please complete and return via fax number 864-***-****. Job Title Term Reason? Correct? _Yes No Pay Rate$ __ Per_ Rehire Eligibility: __ _ Please rate the performance: Below Averacie Averaae Above Averaae NOTES: Work Performance

Attendance

Referee Name: Title: Signature: Date: _ PSI-107

Contact this candidate