Date:____________________________________________________________________________________
Name:____________________________________________________________________________________
Address:__________________________________________________________________________________
_________________________________________________________________________________________
Home Phone:______________________________________________________________________________
Work Phone:______________________________________________________________________________
Social Security Number:______________________________________________________________________
Date of Birth: ______________________________(DOB is
requested in order to obtain accurate retrieval of records.)
Driver’s
License #______________________________________________ State________________________
In connection with any
application made by me, I understand that you may be requesting information
from various Federal, State, and other agencies which maintain records
concerning past activities relating to my credit, criminal, driving, civil, and
other records and experiences, including claims involving me in the files of
insurance companies, if any. These
reports may also include information on education, employment experience, work
habits, mode of living, general reputation, character, along with reasons for
termination of employment from previous employers, if any, as well as previous
salary(ies). I agree, that should I
become an employee, my employer has the right to obtain any and all reports, at
any time, during my employment.
Without reservation, I
authorize any party or agency contacted to furnish the above-mentioned
information and release all parties involved from any liability and/or
responsibility for doing so. I hereby consent
to any potential employer obtaining such information from Argus Search, Inc.
and/or any of their agents. This
authorization and consent shall be submitted in an original, fax, email or copy
form.
I, my heirs, personal
representatives, successors and assigns, hereby release and hold harmless
Argus-Search Inc. and employer, and any of their employees, agents, directors,
or commissioners from any and all liability, claims, claims bills or relief
acts or legislative petitions, damages, both compensatory and punitive, costs
and attorney’s fees, whether arising at law or in equity, which may at any time
arise out of the retrieval, distribution, storage or use of my criminal history
for determination of my fitness as determined by the personnel or human resource
staff, to be an employee of, or maintain my employment with.
I have the right to make a
request to Argus Search, Inc., upon proper identification and payment of any
authorized fees, the information in its files on me at the time of my
request. Argus Search, Inc. does hereby
agree to provide the requested information in accordance with the Fair Credit
Reporting Act and submit a written report via U.S. mail email, or fax.
By signing below, I acknowledge that I have read and
understand this Authorization and Release form.
Signature: X_____________________________________________________________________________
Argus
Search, Inc. ± PO Box 2939 ± Mesquite NV 89027
Phone: 702-613-4931 ± Fax: 866-212-2187