Background Investigation Authorization Form

(Please Read Carefully Before Signing)

The items of personal information requested below are needed to process your background investigation. This information is intended solely for that purpose and will not be used in a discriminatory manner by the parties noted below in the making of appropriate business decisions.

Print Full Name of Applicant:


First	Middle	Last

Other names you have used, including maiden name and the date(s) your name(s) changed:

Race _____________________

Gender: __ Male __ Female

Social Security # ____-____-____

Date of Birth ____-____-____

Driver's License _____________

State of Issue ____________

Phone number where you can be reached if we have questions regarding this form: ( ) ____-____

List all your addresses for the past seven (7) years, starting with the most recent: (Must include present address)

Street Address	City	State	County	Zip Code	From Mo./Yr.	To Mo./Year

Have you ever been convicted of a crime (Other than minor traffic offenses)? Yes__ No__

If Yes, Please Explain Charges: (Use an additional sheet of paper if necessary)

What State, What County and What Year did these convictions occur?

I authorize __________________________ and/or Oxford Document Management and their agents to investigate my background as it pertains to employment, appointment or volunteering considerations. This may include information contained in public records which could include credit history, criminal files at the county, state and federal jurisdiction levels, motor vehicle records and investigations of employment history and performance and educational credentials. I hereby release all persons, companies or corporations furnishing such information from liability and responsibility. A photo static copy of this document can be substituted for the original. This document shall be valid for a period of 1 (one) year from the date of my signature.

Signature of Employee

Date