Background Consent Application

Education and Training

High School NameHigh School Address

Did you graduate high school?

YesNo

G.P.A.

College/Trade NameCollege/Trade Address

Did you graduate?

YesNo

G.P.A.

Work History Recent Employment

Employment Start DateEmployment End Date

AddressPosition(s)

Immediate SupervisorReason for Leaving

Work History Prior Employment

Employment Start DateEmployment End Date

AddressPosition(s)

Immediate SupervisorReason for Leaving

Work History Prior Employment

Employment Start DateEmployment End Date

AddressPosition(s)

Immediate SupervisorReason for Leaving

Work History Prior Employment

Employment Start DateEmployment End Date

AddressPosition(s)

Immediate SupervisorReason for Leaving

The information I have provided is complete and accurate to the best of my knowledge. I also understand that providing the information may disqualify me from further consideration.

I authorize this agency to contact:

My previous employers
Schools I attended
Personal references I have listed

I also authorize this agency to make any investigation(s) of my personal, financial, and/or credit background (including, but not limited to) obtaining a credit report (also known as a "consumer report" under the Fair Credit Reporting Act/Consumer Reporting Act) for the purpose of evaluating my qualifications for employment. This authorization extends for twelve months from today's date.