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BACKGROUND INVESTIGATION AUTHORIZATION

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BACKGROUND INVESTIGATION AUTHORIZATION Powered By Docstoc
					                                                   BACKGROUND SCREENING
                                             NOTIFICATION & AUTHORIZATION FORM

     The purpose of this form is to notify you that a consumer report will be run on you in the course of consideration of an
     employment background check.

                                                         PEOPLE MOVERS                                       ACCT 4421



Applicant Information (Complete the following information as accurately as possible. Please Print or Type)
Last Name                                                            First Name                        Middle Name
 Fineblum                                                            Charles                           Barnard

 Social Security Number                Date of Birth                 Previous Names     (maiden/marriage, etc)
 219-50-9998                           07-22-1959                                                      Date Changed:

 Driver’s License Number               State of Issue                Previous Names
 F-514-115-081-577                     Maryland                                                       Date Changed:




Address History (Include 7 years of History)
 Address #1
 Date From: 05/2003                   Date To:Present
 Street Address                                                      City                               State       Zip
 15116 Red Clover Drive                                              Rockville                         MD           20853


 Address #2
 Date From: 05/1991                   Date To: 05/2003

 Street Address                                                      City                               State       Zip
 9360 Breamore Court                                                 Laurel                            MD           20853


 Address #3
 Date From: 11/1972                   Date To: 05/1991

 Street Address                                                      City                               State       Zip
 5113 Lupine Court                                                   Rockville                         MD           20853




Education History (Highest Degree/Diploma Received)
 Dates of Enrollment
 Date From: 01/1984                   Date To: 06/1989
 Graduation Date: 06/1989             Degree: BS Economics           Name at Graduation: Charles Fineblum

 Name of School Institution                                          Campus & City                      State       Zip
 University of Maryland University College                           College Park                      MD           20783



                                                                           nd
                                                         (continued to 2        page)



                      1800 30th Street, Suite 204, Boulder, CO 80301  (303) 442-3960  442-1004  (800) 433-6010
                                                     BACKGROUND SCREENING
                                               NOTIFICATION & AUTHORIZATION FORM


  Employment History (Provide all employment history for the last 7 years / attach an additional sheet if needed)
   Dates of Employment
   Date From: 08/2009                      Date To: 12/2009                         May we contact your current employer? Yes or No

   Position/Title: Contractor              Supervisor: Marty Bishop                 Phone: 410-470-3500

   Company Name                            Address                                  City                          State     Zip
   Constellation Energy                    City
                                           111 Market Place, #500                   Baltimore                    MD         21202


  Employment History
   Dates of Employment
   Date From: 03/2009                    Date To: 08/2009
   Position/Title: Contractor            Supervisor: Rich Andrews                   Phone: 703.667.7000
   Company Name                              Address                              City                            State     Zip
   GridPoint                                 City Clarendon Blvd, #100
                                             2801                                 Arlington                      VA         22201


   Dates of Employment
   Date From: 08/2008                    Date To: 03/2009
   Position/Title: Contractor            Supervisor: John Batzer                    Phone: 301.621.8900
   Company Name                              Address                              City                            State     Zip
   KeyLogic (Visa Project)                   8825
                                             City Stanford Blvd., #210            Columbia                       MD         21045


   Dates of Employment
   Date From: 03/2008                    Date To: 07/2008
   Position/Title: Contractor            Supervisor: Craig Park                     Phone: 301-354-8050
   Company Name                              Address                              City                            State     Zip
   RCM (OCC Project)                         1445
                                             City Research Blvd., #120            Rockville                      MD         20850



  BACKGROUND SCREENING AUTHORIZATION

  As part of the employment screening process, I authorize all corporations, former employers, credit agencies, educational institutions, law
  enforcement agencies, city, state, county and federal agencies, military services and persons to release information they may have about me to
  the person or company with which this form has been filed, or their agent, Background Information Services, Inc. This releases the aforesaid
  parties from any liability and responsibility for collecting this information.

  I specifically authorize a consumer credit report to be run and authorize the release of my motor vehicle driving records maintained by law
  enforcement agencies, city, state, county and federal courts, or any other state or local agency.

  This authorization, in original or copy form, shall be valid for this and any future reports or updates that may be requested. I understand that
  personal information being collected is necessary to conduct an investigation of my background and that information will be u sed solely for
  this purpose. Based on certain information repository requirements, I may be asked to provide an original signature to authorize the
  investigation of my background. I further acknowledge that a facsimile (FAX) or photographic copy of this release will be valid as the original.




Applicant Signature:                                                                      Date:
                   1800 30th Street, Suite 204, Boulder, CO 80301  (303) 442-3960  442-1004  (800) 433-6010

				
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