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Sample Release Form
A background check is never to be run on
anyone who has not provided written permission by signing a release
form. Below is the text of a sample release form. It may be downloaded
as a Word document.
Download:
sample_release.doc
PRE-EMPLOYMENT AND CONTINUED EMPLOYMENT/VOLUNTEER
DISCLOSURE AUTHORIZATION AND RELEASE
I understand that in connection with my application for
Employment, Volunteer Services, and/or Continuous Employment, and/or
Volunteer Services ___________________________________, its consultant
in, IntelliCorp, their agents or employees may be performing,
requesting, obtaining or conducting a background check on me. This
background check may include an inquiry into my Employment History,
Education, General Character or Reputation, Work Experience, Volunteer
Experience, Driving, and/or Criminal History. If my position involves
handling money and/or having access to monies and/or other transferable
monetary instruments, my Credit History may also be checked.
I understand that ___________________________________ may rely on any
part of all of this Information in determining whether to extend an
offer of Employment / Volunteers’ duties to me. I further understand
that if any adverse action is taken by
___________________________________, or if
___________________________________ chooses not to extend an offer of
Employment / Volunteer duties to me based upon the Information, that I
will be provided a copy of such Information along with a summary of my
rights under the Fair Credit Reporting Act.
I understand that the background check, which may be performed by
Investigators, is being performed as part of the process to evaluate me
prior to Employment / Volunteer assignments, and is not conducted for
any purpose other than in connection with my Application for Employment,
Volunteer status and/or my eligibility for Continued Employment /
Volunteer Duties.
I have read this Pre-Employment and Continued Employment / Volunteer
Disclosure and by signing below, hereby authorize Investigators to
conduct a background check as described herein in conjunction with my
application for employment / volunteer duties. I hereby release any and
all Investigators, including ___________________________________, from
any and all liability related to the procurement or disclosure of any
information provided by me or obtained about me in connection with my
Application with Employer / Organization to the Synod of the Sun and its
affiliated churches, agencies and institutions. I further direct and
authorize Investigators to conduct the background check and further
authorize any third parties who may be the custodians of or in
possession of the requested Information, to disclose such Information to
Investigators in connection with this background check.
Although furnishing your Social Security Number is not optional, it
shall be used for NO other purpose than to make the process for
conducting a background search more accurate. It shall not be sold, or
in any way transferred to a third party except for the express purpose
of conducting the background check.
Applicant Signature:
Date:
Printed
Name:
Social
Security Number:
Date of
Birth:
Former Last
Name(s) if applicable:
Current
Address:
Former
Address:
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