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The information
requested below is for the sole purpose of conducting a background
investigation which may include a credit report, criminal records
check, driving record, and other reports. The information regarding
age, sex, or race will not be used as part of any hiring, promotion,
or termination decision.
Full Name (no
nicknames):________________________________ S.S.N.:_________________________
Other names previously used and when (maiden names, nicknames, etc.):_________________________
Date of Birth:________________
Driver's License Number:_____________________ State:_____
Have you ever
been convicted of a crime? Yes____ No____
If yes, give details:______________________________________________________________________
ADDRESS
Current: _____________________________________________________________________________
_____________________________________________________________________________
Previous: _____________________________________________________________________________
_____________________________________________________________________________
Previous: _____________________________________________________________________________
_____________________________________________________________________________
EDUCATION
| Institution
|
Location |
Degree |
Dates
Attended |
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
I _________________________
hereby authorize the recipient of this release to search any of
the following files which the recipient possesses, and to release
the contents of those files to Executive Placement Associates and/or
Employment Information Service (EIS, Inc.):
1. Federal,
state, or county criminal history records
2. Financial History
3. Education records
4. Social Security Number Verification
I authorize
the reporting of the contents of any of the above records to Executive
Placement Associates or Employment Information Service (EIS, Inc.).
I release the recipient of this release, the prospective employer
named below and Executive Placement Associates or Employment Information
Service (EIS, Inc.) from any and all liability for obtaining and
releasing such information.
Applicant Signature:______________________________
Date: _____________
Prospective
Employer: _________________________________________________
FAX # (301) 287-8317
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