Request for

Employment Background Check

Customer # 000742

 

Social Security Number

          -         -

Date of Birth (Month/Day/Year - for identification purposes only)

        /        /

 

Full Name (First / Full Middle Name / Last)

 

 

Other Names Used (maiden names, AKA names, etc.)

 

 

 

Current Residential Address

 

 

City

State

Zip Code

 

 

 

List each CITY, STATE and ZIP CODE (if known) where you have lived during the past seven years:

 

City

 

 

State

Zip Code

From Date

To Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Driver’s License Number

 

 

State of Issue

 

 

NOTICE TO RESIDENTS OF CALIFORNIA, MINNESOTA AND OKLAHOMA ONLY:  If you would like to receive a copy of your background information obtained by Universal Background Screening, please indicate by checking the following box:    Yes, please send me a copy of my report.

 


APPLICANT DO NOT WRITE IN THIS BOX – FOR EMPLOYER USE ONLY:

Your standard package will be automatically performed unless you specify otherwise below:

 

Perform selected services in addition to standard package

Perform selected services in place of standard package

39-Month driving record
Social Security Address/Alias Trace
Additional County Criminal History Searches
    (check box next to addresses above)

Educational Degree Verification
Personal/Prof. Reference Verification
Professional Licensure Verification
Previous Employment Verification

Phone 602-263-8033 or 1-877-263-8033

Fax orders to 602-274-3551

 

 

 

 

 

COMBINED DISCLOSURE NOTICE AND AUTHORIZATION REGARDING INVESTIGATIVE CONSUMER REPORTS

 

I understand that as a condition of my consideration for employment, or as a condition of my continued employment, Westwind Academy (“the company”) may obtain a consumer report and/or investigative consumer report that includes, but is not limited to: employment and education verifications; social security number verification; criminal and civil court records; personal interviews; driving records; and/or any other public records or any other information bearing on my character, general reputation, personal characteristics and trustworthiness. 

 

I hereby authorize and consent the company and/or its designated agent, Universal Background Screening, to procure such a report. I understand that pursuant to the Federal Fair Credit Reporting Act, Westwind Academy will provide me with a copy of any such report if the information contained in such report is, in any way, to be used in making an adverse decision regarding my fitness for employment. I further understand that such report will be made available to me prior to any such adverse decision being made, along with the name and address of the reporting agency that produced the report.

NOTICE TO RESIDENTS OF CALIFORNIA, MINNESOTA AND OKLAHOMA ONLY:
If you would like to receive a copy of your background information obtained by Universal Background Screening, please indicate by checking the following box: 

  Yes, please send me a copy of my report.

 

 

___________________________________     _____________________

Signature                                                                   Date

 

___________________________________     _____________________

Printed Name                                                            Social Security Number