Authorization To Verify Information

Step 1 of 2

Personal Information

Last Name

Middle Name

First Name

Street Address Address Line 2 City State ZIP Code

Dates Lived Here (MM/DD/YYYY- MM/DD/YYYY)

Addresses for the past seven years:

Street Address Address Line 2 City State ZIP Code

Dates of Residence (MM/DD/YYYY- MM/DD/YYYY)

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Additional Address

Street Address Address Line 2 City State ZIP Code

Dates of Residence (MM/DD/YYYY- MM/DD/YYYY)

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Additional Address

Street Address Address Line 2 City State ZIP Code

Dates of Residence (MM/DD/YYYY- MM/DD/YYYY)

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Additional Address

Street Address Address Line 2 City State ZIP Code

Dates of Residence (MM/DD/YYYY- MM/DD/YYYY)

Personal Information (continued)

Date of Birth

Other Names Used (including maiden name)

Years used

Social Security Number (XXX-XX-XXX)

Driver's License #

State

Expiration Date

Email address: (may be used for official correspondence)

Authorizations

I do hereby authorize verification of all information in my employment application from all sources of employment, education, motor vehicle, financial history, criminal history, personal character, and worker's compensation records in accordance with ADA, labor and wage records, etc. or any part thereof, and authorize any duly authorized agent of IntelliCorp Records, Inc to obtain, whether the said records are public or private, and including those which may be deemed to be privileged or confidential in nature and I release all persons from liability on account of such disclosures. Information appearing on this Authorization will be used exclusively by IntelliCorp Records, Inc for identification purposes and for the release information which will be considered in determining any suitability for employment. I certify that I have made true, correct, and complete answers and statements on my employment application, any supplements to it and in any interview in the knowledge that they will be relied upon in considering my application for employment. I agree to provide additional information that may be requested to process my employment application. I authorize without reservation, any party or agency contacted by IntelliCorp Records, Inc to furnish the above-mentioned information. This authorization is valid during the course of my employment to the extent permitted by law. This will authorize immediate inquiries to the Human Resources Department and to any listed supervisors or references in the Employment/Reference Section of your application. I understand and agree that any omission, false statement, misleading statement, or answer made by me on my application or any supplements to it and in any interviews will be sufficient grounds for rejection of employment and my discharge after employment. I have the right to make a request to IntelliCorp Records, Inc, upon proper identification, to request the nature and substance of all information in its files on me at the time of my request, including sources of information, and the recipients of any reports on me which IntelliCorp Records, Inc has previously furnished within the two year period preceding my request.(Required)

I do hereby authorize verification of all information in my employment application from all sources of employment, education, motor vehicle, financial history, criminal history, personal character, and worker's compensation records in accordance with ADA, labor and wage records, etc. or any part thereof, and authorize any duly authorized agent of IntelliCorp Records, Inc to obtain, whether the said records are public or private, and including those which may be deemed to be privileged or confidential in nature and I release all persons from liability on account of such disclosures. Information appearing on this Authorization will be used exclusively by IntelliCorp Records, Inc for identification purposes and for the release information which will be considered in determining any suitability for employment. I certify that I have made true, correct, and complete answers and statements on my employment application, any supplements to it and in any interview in the knowledge that they will be relied upon in considering my application for employment. I agree to provide additional information that may be requested to process my employment application. I authorize without reservation, any party or agency contacted by IntelliCorp Records, Inc to furnish the above-mentioned information. This authorization is valid during the course of my employment to the extent permitted by law.

This will authorize immediate inquiries to the Human Resources Department and to any listed supervisors or references in the Employment/Reference Section of your application.

I understand and agree that any omission, false statement, misleading statement, or answer made by me on my application or any supplements to it and in any interviews will be sufficient grounds for rejection of employment and my discharge after employment.

I have the right to make a request to IntelliCorp Records, Inc, upon proper identification, to request the nature and substance of all information in its files on me at the time of my request, including sources of information, and the recipients of any reports on me which IntelliCorp Records, Inc has previously furnished within the two year period preceding my request.

I agree to the statement above:

I hereby do authorize you to contact my current employer for Employment and Reference Verifications(Required)

I agree

I disagree

Full Name(Required)

Applicant Signature(Required)

Date(Required)

CALIFORNIA, OKLAHOMA, and MINNESOTA RESIDENTS ONLY: If you are a current California, Oklahoma, or Minnesota resident and would like a copy of your Consumer Report or Investigative Consumer Report, please check the box. This report may include character and reputation information obtained through personal interviews

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