HDI Background Investigation Consent Form

Disclosure In relation to your application for employment, or your current employment, your prospective employer/employer may obtain a consumer report or an investigative report. Such reports may include information as to your character, general reputation, associates and ability to perform. Also subsequent reports may be requested to update, renew or extend employment. This disclosure is given to you in compliance with the Federal Fair Credit Reporting Act and applicable state law. You have the right to request additional disclosures as to the nature and scope of the investigation from your prospective employer/employer. Such request must be made in writing.

The following information is for the sole purpose of undertaking an employment background investigation.

Current Name:

First Middle Last

Maiden Name:

First Middle Last

Address: (No PO Box)

Street City State Zip

Day Phone Evening Phone

Social Security Number Gender

Date of Birth* Month Day Year
 

Employment Desired

Position Desired
Are you Employed? If so, may we inquire of your present employer?
Have you ever applied to this company before? Where? When?



Professional Licenses:

Type # State Issued Date Issued

Type # State Issued Date Issued

Type # State Issued Date Issued

 

Education History

High School:
Name Location of school years attended Did you graduate? Subject Studied

College:
Name Location of school years attended Did you graduate? Subject Studied
(Make room just in case applicant attended more than one college)

Graduate School:
Name Location of school years attended Did you graduate? Subject Studied
(Make room just in case applicant attended more than one graduate school)

Trade, Business or correspondence school:
Name Location of school years attended Did you graduate? Subject Studied

 

Former Employers (List below last four starting with last one first)

From To Name & Address of Employer Position Reason for leaving

From To Name & Address of Employer Position Reason for leaving

From To Name & Address of Employer Position Reason for leaving

From To Name & Address of Employer Position Reason for leaving

 

References

Name: Contact Information Business Years Known

Name: Contact Information Business Years Known

Name: Contact Information Business Years Known



List your previous addresses for the last ten years:

Street City State Zip

Street City State Zip

Street City State Zip

Street City State Zip


Have you ever been convicted of a misdemeanor or felony?
Do you have any pending charges against you at this time?  

If yes, where: Date of Offense:
Nature of Offense:
Court: Case #
Please Explain:

If yes, where: Date of Offense:
Nature of Offense:
Court: Case #
Please Explain:

A conviction record will not necessarily be a bar to employment. Factors such as job relatedness, age at the time of the offense, type of offense, and rehabilitation will be taken into account.
______________________________________________________________________________________

Authorization Release – I certify receipt of this notice and the attached summary of rights and herby give permission to my prospective employer/employer and its agents to verify the information submitted by me and to conduct a background investigation on me. I understand this may include social security number verification and address history, criminal history, driving history, a credit report, education history, license/certification verification past employment, reference checks and /or other public records. I authorize the complete release of these records. Such verification shall not constitute a violation of my right to privacy in any manner and I hereby release them from all liability whatsoever for actions related to this information. I understand that the sole purpose of obtaining this information is for employment reasons. I understand that I must provide my date of birth to adequately complete the background investigation, and acknowledge that my date of birth will not affect any hiring decision.

Name:

Email:

Date:

* This information is for the consumer report purposes only. The Age Discrimination in Employment Act of 1967 prohibits discrimination on the basis of age with respect to individuals who are at least 40 years of age.

Company's E-mail Address:

Name of the Organization Requesting the BI:

Your Name:

File #:



 

HDI Investigation & Executive Protection Service, Inc. is Licensed by the State of North Carolina, New Jersey and by the New York State Department of State