Authorization Release

  1. I understand that an investigative report may be generated on me that may include information as to my character, general reputation, personal characteristics, or mode of living; work habits, performance or experience, along with reasons for termination of past employment/professional license or credentials; financial/credit history; or criminal/civil/driving record history. I understand that Universal Screen may be requesting information from public and private sources about any of the information noted earlier in this paragraph in connection with or consideration of me for employment, promotion or position re-assignment or contract now, or at any time during my tenure with the employer named below and I give my full consent for this information to be obtained.

  2. I acknowledge that a telephonic facsimile (FAX) or photographic copy of this release shall be as valid as the original. This release is valid for most federal, state and county agencies.

  3. I hereby authorize, without reservation, any financial institution, law enforcement agency, information service bureau, school, employer or insurance company contacted to furnish the information described in Section I.

First
Middle
Last
Maiden
A copy of this form will be sent to this email address

Current Address

Enter number and street name (Including Apartment/Suite number)

The following information is required by law enforcement agencies and other entities for positive identification purposes when checking public records. It is confidential and will not be used for any other purposes.

MM/DD/YYYY (Enter month, day and 4-digit year)
Number
Please provide the county and state of charges and details in the space provided.
Please provide the county and state of conviction and details of conviction.
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FAIR CREDIT REPORTING ACT NOTICE:

I acknowledge receipt of the attached summary of my rights under the Fair Credit Reporting Act and, as required by law, any related state summary of rights (collectively “Summary of Rights”). This consent will not affect my ability to question or dispute the accuracy of any information contained in a Report. I understand if the company makes a conditional decision to disqualify me based all or in part on my Report, I will be provided with a copy of the Report and another copy of the Summaries of Rights, and if I disagree with the accuracy of the purported disqualifying information in the Report, I must notify the Company within five days of my receipt of the Report that I am challenging the accuracy of such information with Sterling. I hereby consent to this investigation and authorize Universal Screen, Inc., to procure a Report on my background.

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