I certify that the statements I have made
are true and correct and without material omission. I understand that making false statements or omitting pertinent facts is sufficient cause
for rejection or dismissal from employment. I authorize obtaining information from any person(s), employers, educational
institutions, licensing authorities, and/or law enforcement agencies concerning
my background, work habits, skill or conduct on the job, with the exception
of past employer(s) I have indicated that are not to be contacted. I hereby release such person or entities from all liability for damages
for issuing such information.
I understand that even after an offer of employment is made,
employment is conditioned on producing proof of (1) U.S. citizenship or
legal authorization to work in the U.S. and (2) birth date and (3) such
other information as may be required. I further understand that
employment does not begin until actual commencement of work and will
require complying with and being bound by safety and other rules and
regulations, and may require working overtime shifts, a rotating
schedule and/or a schedule other than Monday through Friday.
When I am employed I agree that if at
any time I make claims for personal
injuries, I will submit myself, upon written request, to examination by a physician or physicians of
at employer's expense, as often as may be
I also agree that if I am employed, now
or at any time in the future, my employment may be terminated at any time without liability to me for wages or salary except for such wages or salary which I earned prior to the date
of my termination. I understand the term of my employment shall be limited to the duration of any assignment
that I accept.
I am aware that Public Law 91-508, known as the Fair Credit Reporting
Act, requires the employer to inform me that a routine inquiry may be made that will provide applicable information concerning
my character, my general reputation, my personal characteristics and my credit history. Upon written request, I will provide additional information
as to the nature and scope of the inquiry or any report which is
I understand that I am applying for temporary or contract assignments. The completion of this application process shall constitute a conditional
offer of employment subject to my availability and the availability of customer assignments calling for the skill and qualifications that I
possess, and I agree to consider acceptance of such assignments.
connection with my application and/or continued employment,
(including contract for services) with you, I understand that
investigative background inquiries are to be made on myself
including consumer investigative criminal convictions. Further, I
understand that you will be requesting information from various
Federal, State, and other agencies, which maintain records
concerning my past activities relating to any criminal experiences.
I acknowledge that I have been counseled that a person or entity may
not procure or cause to be prepared an investigative consumer report
on any consumer unless it is clearly and accurately disclosed to the
consumer, that an investigative consumer report – including all
applicable information as to his or her character, general
reputation, personal characteristics, mode of living, education
history, driving history (including but not limited to accident
history, alcohol/drug and any other DOT requirements as permitted by
the ADA) employment history and credit history – may be made. If
you are denied employment because of the consumer investigation, it
is your right under the Fair Credit Reporting Act (Law 91-508) SS
606. to have the name of the agency or agencies from whom
information concerning you was obtained. You are also entitled to
receive free copies of the information supplied by those agencies
within sixty days upon written request. You have the right to
directly dispute with the consumer reporting agency the accuracy and
completeness of any information furnished by that agency.
authorize without reservation, any party or agency contacted by this
employer to furnish the above mentioned information.
release BACKGROUND NETWORK, INC. d.b.a. CRIMCHECK.COM and any other
person and/or agencies from any suits, liens, judgments, damage
and/or liability resulting from this process.
above information is used solely for inquiries and criminal history
Falsifying any information on this release form will constitute
grounds for immediate dismissal or declining any pending job offers.