CONSENT TO PROCUREMENT OF INVESTIGATIVE CONSUMER REPORT
(Complete form below and click submit at bottom)
I understand that, as a condition of my consideration for employment with CLOUD CHOMP, or as a condition of my continued employment with CLOUD CHOMP, CLOUD CHOMP may obtain an investigative consumer report from CAREY CONSULTANTS, INC., that includes, but is not limited to, my CREDITWORTHINESS or similar characteristics, employment and educational verifications, social security verification, criminal and civil history, personal interviews with references and supervisors or anyone else who may have knowledge of my background, DMV records, any other public records and any other information bearing on my credit standing, credit capacity, character, general reputation, personal characteristics and trustworthiness. I authorize CAREY CONSULTANTS, INC., to contact any of my previous employers, references, supervisors, etc. CAREY CONSULTANTS, INC. may also obtain DOT information if that is a necessary part of their employment screening process. I hereby authorize and consent to CLOUD CHOMP’s procurement of such a report from CAREY CONSULTANTS, INC., I understand that, pursuant to the federal Fair Credit Reporting Act, CLOUD CHOMP will provide me with a copy of any such report if the information contained in such report is considered to be adverse and would preclude CLOUD CHOMP from offering me the position or would negatively impact their decision regarding my fitness for employment, transfer or promotion within the company. I further understand that such report will be made available to me prior to any such decision being made, along with the name and address of the reporting agency that produced the report. I understand that CLOUD CHOMP has a right to re-check my background at anytime during my employment tenure or re-application process without further notification. I understand further that although this is a background form and NOT an employment application, if I provide any false or misleading information CLOUD CHOMP may immediately disqualify me for any position, transfer or promotion.
Digital Signature Release
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Section
I: Candidate DATA
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Last
name |
(required) |
First
name |
(required) |
Middle
Int |
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Date
of Birth |
(required) |
Email Address |
(required) |
Social
Security # |
(required) |
Alias Please indicate any other last names used & years
they were utilized: |
|
Street
address |
|
City |
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State/Zip |
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Home Phone |
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Have you been terminated from any place of employment
within the past 7 years? |
Yes
No
|
If yes, indicated place of employment, cause for
discharge & month/year this termination took place: |
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Please list addresses for the past 10 years:
1.
2.
3. |
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Section II: Employers DATA
|
Most recent Employer |
|
Complete Address |
|
Dates
of Employment |
to
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Your
title
|
Supervisor’s
name
|
Employer
Phone number
|
Reason
for leaving
|
If
you are still presently employed, may we contact?
|
Yes
No
|
2nd Employer |
|
Complete
Address |
|
Dates
of Employment |
to
|
Your
title
|
Supervisor’s
name
|
Employer
Phone number
|
Reason
for leaving
|
3rd Employer |
|
Complete
Address |
|
Dates
of Employment |
to
|
Your
title
|
Supervisor’s
name
|
Employer
Phone number
|
Reason
for leaving
|
Please list 3 PROFESSIONAL references (example;
supervisors, professional colleagues, etc): |
1st reference- Company
|
Relationship
Telephone
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2nd reference- Company
|
Relationship
Telephone
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3rd reference- Company
|
Relationship
Telephone
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Have you been terminated from any place of employment
within the past 7 years? |
Yes
No
|
| If yes, indicated place of employment, cause for
discharge & month/year this termination took place: |
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Section
III: Driver's Information |
Driver's
License # |
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State issued |
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Has your license ever been revoked or suspended? |
Yes
No
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If yes, explain dates & Circumstances:
|
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If you do not have a driver’s license, please explain why
not: |
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Have you ever been convicted of a crime other than a
minor traffic violation? |
Yes
No
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If yes, please explain, giving dates, locations
& circumstances |
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Section
IV: Education |
Please list the most recent school, college; professional
school or trade school you attended: |
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Institution name & location |
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Degree/Yr earned: |
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If you only attended & received no degree, please
list dates of attendance: |
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Please indicate any further education you feel is
relevant to the position for which you are applying: |
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Section
V: Military Experience |
Branch |
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Rank
|
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Dates
|
to
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Did
you receive an Honorable Discharge |
Yes
No
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If
not, please explain: |
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Please
list any former last names & years used: |
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Special
instructions or additional information you need searched:
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