8850 Tyler Blvd., Mentor, OH 44060 • Phone (800) 991-9694 • Fax (440) 205-8355
Visit our website at: www.backtracker.com or email us at: firstname.lastname@example.org
CREDIT RELEASE AUTHORIZATION
In connection with my application for employment with your company, I hereby authorize BackTrack, Inc.,
to furnish a consumer credit report regarding me.
The information from the credit report will not be used in violation of any Federal or State Equal Employment
Opportunity Law or Regulation. You have the right to obtain a copy of the report and the right to dispute any
information, contact BackTrack, Inc. at (800) 991-9694.
I HEREBY AUTHORIZE, WITHOUT RESERVATION, ANY INFORMATION SERVICE BUREAU
CONTACTED BY BACKTRACK, INC., TO FURNISH THE ABOVE-MENTIONED CREDIT
For residents of California, Minnesota and Oklahoma ONLY: Per state laws you are entitled to receive a copy of your consumer
credit report directly from the credit bureau. If you wish to receive this report please check this box.
APPLICANT: Please provide us with the following (print clearly):
Social Security Number
(State address number and street name)
(City) (State) (Zip)
EMPLOYER REQUESTING REPORT (please fill in)
Address, City, State, Zip: