Credit and Employment Reference Authorization

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									An Authorization to Check Credit and Employment Reference allows a company to
collect data and check the references of a potential employee. The information verified
includes, but is not limited to, the employee's previous employment, character
references, credit history, criminal history, and educational qualifications. This form is
ideal for small businesses that want to obtain permission from potential employees to
conduct background checks.
As part of its due diligence procedures, [COMPANY] requires that a background investigation
and a check of references be conducted. It is expressly understood that any information given is
to be used for the purpose of determining my acceptability for employment with [COMPANY].

I voluntarily authorize [COMPANY] or any of its officers, employees, or agents to check my
references by contacting any person or entity whom they deem appropriate. By my signature
below, I also authorize disclosure of information concerning my employment history, earnings
history, education, credit history, credit capacity and credit standing, driving record history and
standing, criminal records and conviction history, pre-employment drug test results, and any and
all other information deemed pertinent by [COMPANY] from the following: my past or present
employers; learning institutions, including colleges and universities; law enforcement agencies;
federal, state and local courts; the military; credit bureaus; and, motor vehicle records agencies.

I also hereby release [COMPANY] from any all liability for damages or claims, which may arise
or result from any reference information gathered pursuant to this authorization.

If I am not hired due to information [COMPANY] learns from my credit report, I will be notified
in writing and a copy of said report will be supplied to me with a written summary of my rights
under the Fair Credit Reporting Act of 1970 as amended in 1996.

Applicant’s Name                                            Social Security Number

Current Street Address                                      City, State and Zip Code

Driver’s License Number and State                           Date of Birth

Signature                                                   Date

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