Company Name: _______________________________________

Contact  Name:_______________________Tel:______________

Circle all that apply / Package: A  B   “Add On”  1  2  3  4  5  6  7

EMPLOYMENT SCREENING AUTHORIZATION

NAME: _________________________________________________________

ADDRESS: ______________________________________________________

CITY, STATE, ZIP: ________________________________________________

SSN: ___________________________________       DOB:________________

DL#: ____________________________________      SEX: ________________

Current and Previous Employers

Name: __________________________________ Tel#:(____)______________

Name: __________________________________ Tel#:(____)______________

Name: __________________________________ Tel#:(____)______________

I give my authorization to verify the above information, obtain a criminal history report, MVR., workers compensation claims and verify employment information (including salary) on myself.

APPLICANT’S  SIGNATURE:  ______________________________________

Fax Completed Form To:  (954) 726-8925