Background Check Form

If you are unable to fill this form out online, please click the link below, download it, fill it out, print and sign it, then email it to your supervisor.

Name*
First Middle Last
Other Names Used and Dates Used
Including Madian Name
Date of Birth*
Social Security Number*
Driver's License Number and State*
Current Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Dates lived at current address*
Address for past 7 years
Previous Address 1
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Dates lived at previous address 1
Previous Address 2
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Dates lived at previous address 2
Previous Address 3
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Dates lived at previous address 3
Authorization to Release Information
Authorization*
I do hereby authorize verification of all information in my employment application from all sources of employment, education, motor vehicle, financial history, criminal history, personal character, and worker's compensation records in accordance with ADA, labor and wage records, etc. or any part thereof, and authorize any duly authorized agent of IntelliCorp Records, Inc to obtain, whether the said records are public or private, and including those which may be deemed to be privileged or confidential in nature and I release all persons from liability on account of such disclosures. Information appearing on this Authorization will be used exclusively by IntelliCorp Records, Inc for identification purposes and for the release information which will be considered in determining any suitability for employment. I certify that I have made true, correct, and complete answers and statements on my employment application, any supplements to it and in any interview in the knowledge that they will be relied upon in considering my application for employment. I agree to provide additional information that may be requested to process my employment application. I authorize without reservation, any party or agency contacted by IntelliCorp Records, Inc to furnish the above-mentioned information. This authorization is valid during the course of my employment to the extent permitted by law.
I authorize verification
I hereby do or do not authorize you to contact my current employer for Employment and Reference Verifications.*
- I do authorize
- I do not authorize
This will authorize immediate inquiries to the Human Resources Department and to any listed supervisors or references in the Employment/Reference Section of your application.
Right to Request*
I have the right to make a request to IntelliCorp Records, Inc, upon proper identification, to request the nature and substance of all information in its files on me at the time of my request, including sources of information, and the recipients of any reports on me which IntelliCorp Records, Inc has previously furnished within the two year period preceding my request.
I understand I have the right to request records.
Understanding of Omission or False Information*
I understand and agree that any omission, false statement, misleading statement, or answer made by me on my application or any supplements to it and in any interviews will be sufficient grounds for rejection of employment and my discharge after employment.
I understand the consequence of omission or false information.
Signature*
Date*
DISCLAIMER: THIS FORM IS NOT MEANT TO PROVIDE LEGAL ADVICE OF ANY KIND. LEGAL ADVICE SHOULD BE SOUGHT FROM YOUR ATTORNEY. WE MAKE NO CLAIMS, PROMISES OR GUARANTEES ABOUT THE ACCURACY, COMPLETENESS, OR ADEQUACY OF THE INFORMATION CONTAINED HEREIN. WE MAKE NO WARRANTY THAT THIS FORM IS APPROPRIATE FOR YOUR PARTICULAR NEEDS.

Address for past 7 years

Authorization to Release Information