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Criminal Background Search
Authorization to Release Personal Record Information
Please Print Top Portion
Name A.K.A.
(Please Print Clearly) First Middle Last
Address City, State Zip
Current
Previous City, State Zip
Previous City, State Zip
SSN DOB (For identification only)
Drivers License Number State issued
List all convictions including traffic and criminal
Criminal Offense(s) Traffic Offense(s)
Year Offense County Year Offense County
1. 1.
2. 2.
3. 3.
4. 4.
I hereby authorize and request any present or former employer, school, police department (Criminal History or Criminal Background Check), financial institution, division of motor vehicles, consumer reporting agencies, or other persons or agencies having knowledge about me to furnish bearer with any and all information in their possession regarding me, in order that my employment qualifications may be evaluated. This information may include: my record of arrests and, or convictions for violations of any federal, state, local statutes or ordinances, my employment history, my credit history, workers compensation history, and driving record. I hereby release any said person, companies or law enforcement authorities from any liability for any damage whatsoever for issuing this information. I further understand this information may be reviewed initially and periodically by PRI, and reported to my prospective employer.
I understand my prospective employer intends to utilize the investigation into my background for employment purposes only, and shall not disclose such information to any other party. I hereby acknowledge that PRI cannot vouch for or guarantee accuracy of information provided by third parties. Accordingly, I release PRI, its agents and / or my prospective employer from any and all liability arising out of any errors or omissions regarding my background information and authorize PRI to release the results of its investigation to my prospective employer.
Applicant signature: Date:
PLEASE SIGN - DO NOT PRINT
California Applicants Only: [_] Check here if you wish to receive a copy of any report that may be generated as a
result of this authorization. (CA. AB655 as amended)
_____________________________________________________________________________________________
Must be completed by client before investigation will be performed
Client: Store/Plant#: Manager:
Date: / / Phone: ( ) Fax: ( )
Manager, please indicate which reports you require
Criminal ______SSN Verification ______MVR ______Statewide for _____
Fax this form to: 800-260-3997
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