AUTHORIZATION FOR RELEASE OF INFORMATION FOR INVESTIGATIVE
CONSUMER REPORT/EMPLOYMENT PURPOSES
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PRIVACY ACT STATEMENT In compliance with the Privacy Act of 1974, the following information is provided: Basic authority for collecting the requested information is contained in E.O. 12450:5 USC 1303-1305;: 42 USC 2165 and 2455: 22 USC 2585 and 2519: and 5 USC 3301. This form will be furnished to individuals and organizations for the purpose of obtaining information from them about you and your activities in connection with an official background investigation concerning: (1) fitness for employment, (2) clearance to perform contractual, (3) security clearance or access to sensitive materials, or (4) any other legitimate purpose within the scope of employment responsibilities. Furnishing the requested information is voluntary, but failure to provide all or part of the information may result in a lack of further consideration for employment, clearance or access, or in the termination of your employment.
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In relation to my recent application for employment with YORK TECHNICAL COLLEGE , I authorize Surveillance, Resources and Investigations, LLC (SR&I, LLC) to construct an investigative consumer report with information pertaining to my background, reputation or disposition, including, but certainly not limited to, facts involving my employment, education, social security number authentication, driving record, consumer credit history (if consumer credit history is relevant for job description it will be verified), criminal record and/or additional public records history. I authorize all parties to release all information applicable to this investigation. I release from liability all persons, governmental agencies, as well as other companies and agencies disclosing any and all information. In addition, I authorize that photocopies of this form may be considered as an original.
I have read, comprehended and authorize, any person, company or other entity contacted by Surveillance, Resources and Investigations, LLC (SR&I, LLC), to provide the information stated above.
This form will not be accepted if illegible, altered or incomplete.
Signature Social Security # Driver’s Lic. # State |
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Print Name Other Names Used (maiden) Years Used |
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Current Address |
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City State Zip County of Residence |
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City State County Dates Lived here |
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City State County Dates Lived here |
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City State County Dates Lived here |
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Have you ever been convicted of a crime other than minor traffic violation? (Circle one) YES NO
Education History
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Name of School Address Telephone # |
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Degree Awarded: Year
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*Date of Birth *Gender (M or F) *This information will only be used to complete the background check process and help avoid misidentification. |
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