Background Request Form
(Fax to 281-895-9968)
________________ pre-screens all applicants before hiring/leasing. This policy was enacted to ensure a professional working environment for our employees, as well as, for the protection of our customers/clients. Please answer the following questions below and sign and date the release on the bottom of the page.
APPLICANT NAME: (first)______________/(middle)______________/(last)__________________________
SOCIAL SECURITY NUMBER: ____________________________________________________________
ALIASES: ____________________________________________________________________________
ADDRESS: /Street/________________________________/City/_______________/State/___________/Zip/_________
PREVIOUS ADDRESS:__________________________________________________________________
	(List all previous address in the last 7 years. Use additional pages if necessary.)
DRIVER'S LICENSE: (number/state) ___________________________ / _______
DATE OF BIRTH: (month/date/year)_______________ / __________ / ________
UNIVERSITY/COLLEGE ATTENDED:___________________________City/State__________________
DEGREE REC'D:___________________________________YEAR CONFERRED: ____________________
PAST EMAIL ADDRESSES USED:(use additional pages if necessary)________________________________
1. HAVE YOU EVER BEEN CONVICTED OF A CRIME IN THE PAST 10 (TEN) YEARS? _____YES_____NO
Location of Records: City____________________________ , State_______, Year __________(If YES, please explain on a separate sheet. )
2. HAVE YOU EVER RECEIVED DEFERRED ADJUDICATION, (Where the final disposition was anything other than "DISMISSED".), FOR ANY CRIME IN THE PAST 10 (TEN) YEARS? THIS INCLUDES ANY PRE-TRIAL DIVERSION PROGRAM. _____YES_____NO
Location of Records: City____________________________ , State_______, Year __________(If YES, please explain on a separate sheet. )
3.DO YOU CURRENTLY HAVE ANY OPEN CRIMINAL CASES PENDING _____YES _____NO
Location of Records: City____________________________ , State_______, Year __________(If YES, please explain on a separate sheet. )
4.HAVE YOU HAD ANY CRIMINAL CHARGES AGAINST YOU DISMISSED IN THE PAST 7 (SEVEN) YEARS? _____YES _____NO
Location of Records: City____________________________ , State_______, Year __________(If YES, please explain on a separate sheet. )
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I understand that in connection with the application process, ________________ will request Advanced Investigative & Screening Solutions, a licensed investigations agency, to conduct a background check on me(consumer report). The information provided by me will be the basis for the search of public records, which may include, but not be limited to, a search for criminal arrests/convictions, warrants, civil filings, social security number trace, past employment, bankruptcies, department of motor vehicle records, fictitious business filings, degree confirmation, articles of incorporation/limited partnership records, and drug test.
I indemnify and hold harmless, ________________, Advanced Investigative & Screening Solutions, and any person providing the requested information, from any liability and all damages whatsoever, resulting from the acquisition, use, retention, or disclosure of any such information. I will not hold ________________, Advanced Investigative & Screening Solutions, or their employees, or agents responsible for errors or inaccuracies in the acquisition or transmittal of information pertaining to the verification of my background.
If any adverse decision is made with regard to my application or employment (if any) based entirely or in part on the information contained in the consumer report, I understand I will be notified as to the basis of that decision and given a copy of the report, as well as a summary of my applicable rights.
I have provided complete and truthful information to ________________ and fully understand that any misrepresentations or material omissions concerning the information provided will be grounds for denying my application, withdrawing any offer of employment, or immediate discharge.
My signature below indicates I have carefully read and understand this notice and consent to the release of a consumer report to ________________ for employment purposes either in connection with my job application, or in connection with any future decisions concerning my employment, promotion, reassignment or retention as an employee. I understand my consent remains in effect indefinitely until it has been revoked in writing.
_____________________________________________      ____________________
Candidate's Signature/ConsentDate
REQUESTED BY: _______________________________ Date ___________________
(By signing, I authorize that a photocopy or facsimile of this form serves as the original)