Employment Background Inquiry Authorization

EMPLOYMENT BACKGROUND INQUIRY AUTHORIZATION I authorize Weiss & Mueller, Ltd., or any other 3rd party, to obtain any and all past employment records regarding previous employment and other areas of my background such as past employer inquiries, retail credit inquiries, criminal record inquiries, driving history, educational records, and drug/alcohol testing results. I agree to hold Weiss & Mueller, Ltd., its client and my past employers, harmless regarding any information that is obtained during the background inquiry. I am aware that this report is prepared under the guidelines of the Fair Credit Reporting Act (FCRA) and I am eligible to receive, upon written request, a copy of the report, if not hired. Applicant: The request for your date of birth is to be used in performing a criminal record search only, and is not used by the client in consideration of employment. If you have a signed authorization, type your initials here Signature on file
CLIENT INFORMATION
Date:
Last Name:
First Name:
Middle Name:
Maiden Name:
Address:
City:
State:
Zip Code:
Social Security Number:
Date of Birth:
License Number:
License State:
May we contact your employer:	Yes No
Please tell us what state to run for the check:
Client & Location:
Email: