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ELDERLY OPPORTUNITY AGENCY, INC. |
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FORM # |
2-4 (g) |
Release Authorization |
REVISED: |
08/01/09 |
I
In connection with my application for employment with you, I understand than an investigative consumer report may be requested that will include information as to my character, work habits, performance and experience, along with reasons for termination of past employment from previous employers. Further, I understand that you will be requesting information concerning my workers compensation claims, motor vehicle operation history including obtaining my official Driving Record or Abstract, credit history and criminal history from various states, private and insurance sources along with other public records available. Workers compensation information will only be requested in compliance with the ADA and/or any other applicable state laws.
I HEREBY AUTHORIZE, WITHOUT RESERVATION, ANY LAWFUL ENFORCEMENT AGENCY, ADMINISTRATOR, STATE AGENCY, INSTITUTION, INFORMATION SERVICE BUREAU, EMPLOYER OR INSURANCE COMPANY CONTACTED BY ORCA INFORMATION, INC TO FURNISH THE ABOVE-MENTIONED INFORMATION.
I further acknowledge that a telephonic facsimile (FAX) or photographic copy shall be as valid as the original. This release includes all state and federal agencies including Minnesota’s Department of Labor. According to the Fair Credit Reporting Act, I am entitled to know if employment is denied because of information obtained by my prospective employer from a consumer-reporting agency. If so, I will be so advised and be given the name of the agency or source of information.
The information submitted is confidential and will be used only for the purpose of determining my suitability for the position which I applied.
Today’s Date: ______________ Signature: ________________________________________
The following must be filled out completely for your application to be considered. (Please print).
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Last Name |
First Name |
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Date of Birth |
Race |
Sex |
Social Security # |
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Place of Birth (City/State) |
Current Address |
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County |
Zip |
Drivers License #/State |
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Other Last names Used |
Other States & Counties I have lived in as an adult |
State |
County |
Zip |
From (yr) |
To (yr) |
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Have you ever been charged or convicted of a crime? Yes ¸ No ¸
If yes, what State & County: __________________________________What was the nature of the crime (give details):________________________________________________________________
The above information is to be used only for identification and investigative purposes and is strictly confidential.
This information is being verified by ORCA Information, Inc. Any information or questions should be directed to the following address:
ORCA Information, Inc.
P O Box 277
Anacortes, WA 98221
(800) 341-0022 / (306) 588-1633