Background Check Form

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Opublikowany 2018-01-31 17:17:39

Page 1 of 2 Authorization for Background Investigation To Whom It May Concern: I, ____________________________________, Hereby authorize STOX Posting & Publishing, Orange Services, or STOX Pro Serve, and/or its agents to make an independent investigation of my background, which may include my character, general reputation, personal characteristics, and mode of living in connection with an application of employment with STOX Posting & Publishing, Orange Services, or STOX Pro Serve. The Scope of the report may include information concerning my driving record, civil and criminal court records, credit, workers’ compensation record, education, credentials, identity, past addresses, social security number, previous employment and personal references. I authorize and request any present or former employer, state/federal government office, state department of motor vehicles, credit bureaus, school, police department, court records, including those maintained by both public and private organizations, financial institution or other persons having personal knowledge about me to furnish STOX Posting & Publishing, Orange Services, or STOX Pro Serve, with any and all information in their possession regarding me for the purpose of confirming the information contained on my application and/or obtaining other information which may be material to my qualifications for employment. I am willing that a photocopy of this authorization be accepted with the same authority as the original, and I specifically waive any written notice from any present or former employer who may provide information based upon this authorization request. The following is my true and complete legal name and all information is true and correct to the best of my knowledge: Print Full Name: ____________________________________________ Print Maiden Name or Other Names Used:__________________________ Present Address: __________________________ City: State: Zip Code: __________________________ Former Address: __________________________ City: State: Zip Code: __________________________ Date of Birth (for I.D. purposes only): __ / ___/_____ Social Security Number: __________________________ Driver’s License Number: State of Issue: __________________________ STOX Posting & Publishing, Orange Services, or STOX Pro Serve will need to contact you if additional information is needed to process your Background Investigation. Please provide a telephone/cell phone number and email address where we may contact you. Phone: (____ ) _________-____________ Cell: (____ ) ___________-___________ Email Address:___________________________________________________________ Signature: ____________________________________________ Signature: Date: ______/_____/_______ Page 2 of 2 California, Minnesota and Oklahoma Residents Only: If a consumer background report is ordered, would you like a free copy of the report mailed to your home? YES □ NO □ Exhibit A Financial institutions comprise a significant portion of STOX Posting & Publishing, Orange Services, or STOX Pro Serve’s (“STOX”) client base. In performing services for those institutions, as well as other clients, all employees of STOX, regardless of position or title, have, to some extent, access to confidential financial information of the STOX’s clients as well as third parties, confidential information, including, but not limited to, third parties’ social security numbers and personal identification information, and attorney-client privileged information. Because of this, and because many of STOX’s financial institution clients require STOX to conduct credit checks on prospective employees, the credit history of an applicant or employee is substantially related to all STOX positions. As a result, STOX conducts credit checks on prospective employees. By consenting to a Background Investigation, you are consenting to an investigation that includes a review of your credit history. I acknowledge that the scope of STOX background investigation of me will include, among other things, a review of my credit history, and I authorize such an investigation. Dated: _______________, 201__ Signature: ____________________________________ Print Name: ____________________________________


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