Fillable Printable Rental Background Check Sample Form

Rental Background Check Sample Form

Authori z ation / Rel ease For m

I hereby authorize Riverbanks Park Commission and its designated agents and representatives to conduct a

comprehensive review of my background causing an investigative consumer report to be generated for

employment purposes.

I understand that the scope of the consumer report/investigative consumer report may include, but is not limited to,

the followi ng areas:

Verification of social security number; current and previous residences; employment history including all

personnel files; education including transcripts; character references; criminal history records from any

cr im inal jus tice agency in any or all feder al, state, county jur isdictions ; birth recor ds; m otor vehicle rec ords

to include traffic citations and registration; and any other public records or to conduct interviews with third

parties relative to my character, employment history, and/or general reputation.

I further authorize any individual, company, firm, corporation, or public agency (including the Social Security

Administration and law enforcement agencies) to divulge any and all information, verbal or written, pertaining to

m e to Riverbank s Park Comm ission or its agents. I f urther authorize the com plete release of any records or data

pertaining to me which the individual, company, firm, corporation, or public agency may have, to include

information or data received from other sources.

I hereby release Riverbanks Park Commission, the Social Security Administration, and its agents, officials,

representatives, or assigned agencies, including officers, employees, or related personnel both individually and

collec tively, f rom any and all liability f or dam ages of whatever k ind, which m ay, at any tim e, res ult to m e, m y heirs ,

family, or associates because of compliance with this authorization and request to release. You may contact me

as indicated below.

I understand this authorization automatically expires 90 days from the date executed below and that I have the

right to revoke the authorization at any time, provided I do so in writing.

Print Name:_________________________________________________________________________________

(First) (Middle) (Last) (Maiden)

Former Name(s) and Dates Used:________________________________________________________________

Current Address Since: __________ ____________________________________________________________

(Mo/Yr) (Street) (City) (State/Zip)

Previous Address From: __________ ____________________________________________________________

(Mo/Yr) (Street) (City) (State/Zip)

Social Security Number: ________________________________ Date of Birth: __________________________

Telephone number: ____________________________________ Gender: Male / Female

Drivers’ License Number/State: _________________________________________________________________

Signature: _____________________________________________________ Date: _______________________

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For Office Use Only:

Status __________________________________ Authorized by _______________________________________