link-to-150-yeart

background check authorization form

Required

Is this for Summer Camp?
In the following spaces please enter your full name, and any names you have used in the past.
Namerequired
First Name
Middle (optional)
Last Name
Enter your current address:
Enter your prior address:
Must contain a date in M/D/YYYY format
Genderrequired

1. In connection with my application for employment or to volunteer, I understand that an investigative consumer report may be requested that will include information as to my character, work habits, performance, and experience, along with reasons for termination of past employment. I understand that as directed by company policy and consistent with the job described, you may be requesting information from public and private sources about my: workers' compensation injuries, driving record, court record, education, credentials, and references.

2. Medical and workers' compensation information will only be requested in compliance with the Federal Americans with Disabilities Act (ADA) and/or any other applicable state laws. According to the Fair Credit Reporting Act, I am entitled to know if employment is denied because of information obtained by my prospective employer from a consumer-reporting agency. If so, I will be notified and given the name and address of the agency or the source, which provided the information.

3. I acknowledge that a telephonic facsimile (FAX) or photographic copy shall be as valid as the original. The release is valid for most federal, state and county agencies.

4. I hereby authorize, without reservation, any law enforcement agency, institution, information service bureau, school, employer, reference or insurance company contacted by Ursuline Academy of Dallas or its agent, to furnish the information described in Section 1. The following information is required by law enforcement agencies and other entities for positive identification purposes when checking public records. It is confidential and will not be used for any other purposes. I hereby release the employer and agents and all persons, agencies, and entities providing information or reports about me from any and all liability.

Namerequired
First Name
Last Name