Contact

Applicant/Employee Information

Full Legal Name *

Other Name(s) Used

Date of Birth *

Phone Number *

Email Address *

Current Address *

City *

State *

ZIP *

Previous Address(es), if applicable

Position Information

Company/Organization Name *

Position Applied For *

Department (if applicable)

Applicant/Employee ID (if applicable)

Disclosure

As part of the employment application, hiring, onboarding, or employment process, the company may obtain consumer reports and/or investigative consumer reports about me for employment purposes.

These reports may contain information permitted by applicable law, which may include information related to identity verification, employment history, education or credential verification, professional licenses, driving records, and criminal history, as applicable to the position and legally permissible.

I understand that the information obtained will be used for lawful employment-related purposes and handled in accordance with applicable federal, state, and local laws.

Authorization

I hereby authorize VeriCore Screening Solutions and/or the company or organization identified above to obtain consumer reports and investigative consumer reports about me for employment purposes, as permitted by law.

This authorization applies to the screening requested in connection with my employment application, hiring, onboarding, or employment, including any legally permissible updates or subsequent reports when separately authorized or otherwise permitted by applicable law.

I understand that I have rights under applicable federal and state law regarding consumer reports, including rights to dispute information that may be inaccurate or incomplete.

Certification

I certify that the information I have provided on this form is true and complete to the best of my knowledge.

I understand that providing false or misleading information may affect my employment application or employment status, subject to applicable law.

Signature & Electronic Signature

Applicant Signature *

Date *

Electronic Signature — sign with your mouse or finger *

Sign above

For Employer/Client Use Only

Company/Client Name

Requested Screening Type(s)

Criminal Background Screening Employment Verification Education Verification Professional License/Credential Verification Motor Vehicle Record Identity Verification

Other

Requested By

Date Submitted

Reference/Order Number

VERICORE SCREENING SOLUTIONS