Background Investigation Authorization Form

(Please Read Carefully Before Signing)

The Fair Credit Reporting Act (Amended 1997) has stipulation that we inform you that a background investigation may be processed as part of our screening and selection process. This investigation may include inquiries to gather legal information regarding your personal characteristics, mode of living, character and general reputation. This information, if gathered, is used to verify that specific information that you provided on an application, resume or during the interview process. Upon your written request, within a reasonable timeframe, the nature and scope of the report, if one is made, will be provided. In addition, if a report is processed, you have a right to request a copy of the report from the consumer reporting agency that provided same report.

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.

Social Security # ____-____-____ Date of Birth ____-____-____
Driver's License _____________ State of Issue ____________
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
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?
Other names you have used, including maiden names and the date(s) your name(s) changed:

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 Potential
Printed Full Name of Applicant  
(MN/CA residents only): Do you wish to receive a copy of your consumer report? Yes____ No____