AUTHORIZATION AND RELEASE

In connection with my application for employment, I understand that an investigative consumer report may be requested that will include information as to my character, work habits, performance, and experience, along with reasons for termination of past employment.  I understand that as directed by company policy and consistent with the job described, you may be requesting information from public and private sources about my: workers= compensation injuries, driving record, criminal record, education, credentials, credit, and references.    I voluntarily and knowingly authorize the company and/or its agents, to verify any aspect of the information contained in my employment application or through public and private sources.  I further understand that misrepresentations or omissions  in my employment application may be cause for rejection or may be cause for subsequent dismissal if I am hired. 

 

Medical and workers= compensation will only be requested in compliance with the Federal Americans with Disabilities Act (ADA).  According to the Fair Credit Reporting Act (FCRA), I am entitled to know if employment is denied because of information obtained by my prospective employer from a consumer reporting agency.  If so, I will be notified and given the name and address of the agency or the source which provided the information.   

 

I voluntarily and knowingly authorize any former employer, person, firm, corporation, school or government agency, its officers, employees and agents to release any and all information concerning my former employment to you or your agents.  I understand that the employment information may include, but is not necessarily limited to, performance evaluation and reports, job descriptions, disciplinary reports, letters of reprimand, and opinions regarding my suitability for employment possessed by it.

 

I voluntarily and knowingly, fully release and discharge, absolve, indemnify and hold harmless you, your agents and any former employer, person, firm, corporation, school or government agency, its officers, employees and agents from any and all claims, liability, demands, causes of action, damages, or costs, including attorney's fees, present or future, whether known or unknown, anticipated or unanticipated, arising from or incident to the disclosure or release of any such information to you, your agents, or consumer reporting agency.

 

I hereby authorize AAIM to procure a consumer report as part of the preemployment background investigation.  If hired, this authorization shall remain on file and shall serve as an ongoing authorization for you to procure consumer reports at any time during my employment period.  I understand that I must provide my date of birth to adequately complete said screening, and acknowledge that my date of birth will not affect any hiring decisions.

 

_________________________________________                _________________

Signature                                                                 Date

 

May your current employer or references associated with your current employment be contacted?

 

YES    9                                                  NO     9

 

The following information is required by law enforcement agencies and other entities for positive identification purposes when checking public records.  It is confidential and will not be used for any other purposes.

 

PLEASE PRINT CLEARLY

Name:    Last	First		Middle
Other Names Used - include maiden name, aliases and nick names
Address:
City/State/Zip
Telephone Number	Social Security Number		Date of Birth
Drivers License Number	State	Sex :   M     F		Race: