Scribd
Upload
32 views

Verifyi Background Check Form

Uploaded by

4jmj8rc9nc
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
32 views

Verifyi Background Check Form

Uploaded by

4jmj8rc9nc
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 1

Background Verification Release Form

AGENCY INFORMATION
Date Agency Name
Hope's Door New Beginning Center
Contact Name
Gilbert Holguin - Director of Operations
Agency’s Main Phone Number Agency’s Fax Number
972-422-2911

APPLICANT INFORMATION:
Applicant Full Name (Last, First, MI) Maiden or Other Name(s) Used
Silva Rubio, Rodrigo, A
Current Address
2028 Savoy St
City State Zip Code County
Dallas TX 75224
Social Security Number Date of Birth Driver’s License Number State Issued
636-19-3942 02/29/2000
Position Applied for Contact Phone Number Email Address
Cashier 2146630572 [email protected]

Gender ^ Male  Female Race  African American  American Indian  Anglo  Asian ^ Hispanic  Other

_______________________________ (the “Organization”) may request a comprehensive review of your background information from a consumer
reporting agency in connection with your employment/volunteer application and for employment/volunteer purposes, including promotion, reassignment,
or retention as an employee or volunteer. Your background information may be obtained in the form of consumer reports and/or investigative consumer
reports. These reports may be obtained at any time after receipt of your authorization and, if you are selected by the organization, throughout your
volunteering or employment VERIFYI, 2800 Live Oak Street, Dallas TX 75204, 214-818-9839, and its designated agents and representatives or another
consumer reporting agency will prepare or assemble the reports. The scope of the consumer report/investigative consumer report may include, but is not
limited to, the following areas: consumer credit, names and dates of previous/current employment, worker’s compensation claims, criminal history
records (from local, state, federal, international and other law enforcement agencies’ records), sexual offender’s lists, wants and warrants records, motor
vehicle records, military records, educational verification, license verification, civil cases, OIG/GSA, OFAC/patriot act, any sanction lists, finger printing
and drug testing. These reports may include information as to your general reputation, character, personal characteristics, mode of living, work habits,
job performance and experience along with reasons for termination of past employment from previous employers. You may request more information
about the nature and scope of any investigative consumer reports by contacting the organization. A summary of your rights under the Fair Credit
Reporting Act is also being provided to you.

Authorization and Release

I, Rodrigo Silva authorize the complete release of these records or data pertaining to me which an individual, organization,
firm, corporation, institution, school or university, law enforcement or public agency may have. I authorize the full release of the information described
above, without any reservation, throughout any duration of my employment/volunteering at the organization. I release all persons or entities from liability
from any alleged damage that may result from furnishing accurate information in good faith to the organization.

I certify that all information provided below is true and accurate to the best of my knowledge. This authorization and consent shall be valid in original,
facsimile (“fax"), or copy form.

The following information is required by law enforcement agencies and other entities for identification purposes when checking records. It is confidential
and will not be used for any other purpose.

PLEASE PRINT LEGIBILY:

08/06/2024
Applicant’s Signature Date

Rodrigo Silva
Applicant’s Printed Name Parent/Guardian’s Signature
(if under 18 years of age)

You might also like