Background Check Authorization

Start Term

First Name

Middle Name

Last Name

Former Name

Date Former Name Used Until

Current Address

Country

Street

City

Region

Postal Code

Current Address Since

Previous Address

Country

Street

City

Region

Postal Code

Previous Address From

Social Security Number

Birthdate

Phone Number

Drivers License Number

The information contained in this application is correct to the best of my knowledge. I hereby authorize Alvernia Unversity and its designated agents and representatives to conduct a comprehensive review of my background causing a consumer report and/or an investigative consumer report to be generated for employment and/or volunteer purposes. I understand that the scope of the consumer report/investigative consumer report may include, but is not limited to the following areas: verification of social security number; current and previous residences; and criminal history records from any criminal justice agency in any or all federal, state, county jurisdictions; driving records, birth records, and any other public records.

I further authorize any individual, company, firm, corporation, or public agency to divulge any and all information, verbal or written, pertaining to me, to Alvernia University or its agents. I further authorize the complete release of any records or data pertaining to me which the individual, company, firm, corporation, or public agency may have, to include information or data received from other sources.

Alvernia University and its designated agents and representatives shall maintain all information received from this authorization in a confidential manner in order to protect the applicant's personal information, including, but not limited to, addresses, social security numbers, and dates of birth.

Signature

By checking this box, I am verifying that I am the student completing this form and this represents my signature.

Notice to California, Minnesota, and Oklahoma Residents Only:
Please check the box below if you wish to receive a copy of a consumer report that is requested.

I wish to receive a copy of any Background Check Report on me that is requested.