Background Screening Consent Form

Personal Information

  

Address History for the last 7 years





Authorization to Release Information and Records

I hereby authorize Hubbard Pipe and Supply, Inc. and/or their agent to conduct an appropriate background investigation of my former employment, education, credit files, and criminal records for determination of my eligibility for employment. I authorize all persons who may have information relevant to this investigation to disclose it to EZ Screen Solutions, LLC and/or their agent. I release and agree to hold harmless all persons providing such information and EZ Screen Solutions, LLC., its officers, directors, employees and agents from liability on account of such disclosure. I hereby further authorize that a photocopy of this authorization may be considered as valid as the original.

These investigations might include, but are not limited to, searches of educational institutions attended; state driving records; financial or credit institutions, including records of loans; records of commercial or retail credit agencies; other financial statements; records of previous employment, including work history, efficiency ratings, complaints and grievances filed by or against me; records and recollections of attorney-at-law or of other counsel, whether representing me or any other person (in either a civil or criminal case in which I have been involved); records from the U.S. Veterans' Administration; criminal history information or files in local, state or federal agencies; and motor vehicle records, and following an employment offer, workers' compensation reports from either the Department of Labor, National Personnel Records or the Industrial Commission or similar agencies under the provisions of the Fair Credit Reporting Act 15 USC section 1681 et seq. I also authorize the National Personnel Records Center, or other custodian of my military service record, to release to EZ Screen Solutions, LLC the following information and/or copies of documents from my military service record: DD-214, service record, and any disciplinary records.

I understand that these searches may be used to determine work assignment, or employment eligibility. Therefore, I authorize and consent for full release of records (either orally or in writing) to the authorized representatives of the company. In addition, I release and discharge the company and its agent and associates to the full extent permitted by law from any claims, damages, losses, liabilities, costs expenses or any other charge or complaint filed with any agency arising from retrieving and reporting this information. I understand that according to the Federal Fair Credit Reporting Act, I am entitled to know whether employment was denied based upon the information obtained and to receive, upon written request, a disclosure of the background report which can take several weeks. I also understand that I may request a copy of the report from EZ Screen Solutions, LLC at 5994 S. Holly St. #151 Greenwood Village, CO 80111 or at telephone number (800) 429-5303. After reading this document, I fully understand its contents and authorize the background verification.

  
  

I hereby certify that all information provided in this authorization is true, correct and complete.