Confidential Background Check Form
Please complete the form below.
Full Name
*
First Name
Middle Name
Last Name
Current Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date you began living at your current address (estimates are OK):
*
-
Month
-
Day
Year
Please enter the date above.
Previous Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date you began living at your previous address (estimates are OK):
-
Month
-
Day
Year
Please enter the date above.
Previous Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date you began living at your previous address (estimates are OK):
-
Month
-
Day
Year
Please enter the date above.
Social Security Number
*
Date of Birth
*
-
Month
-
Day
Year
Please enter the date above.
The information contained in this application is correct to the best of my knowledge. I hereby authorize Destiny Transportation, Inc. 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 an investigative consumer report to be generated for volunteer purposes.
I understand that the scope of the consumer report may include, but is not limited to the following areas: verification of social security number; current and previous residences; employment history; education background; character references; drug testing; civil 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 (including the social security administration and law enforcement agencies) to divulge any and all information, verbal or written pertaining to me, to Destiny Transportation, Inc. 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.
I hereby release Destiny Transportation, Inc. the Social Security Administration, and its agents, officials, representatives, or assigned agencies, including officers, employees, or related personnel both individually and collectively, from any and all liability for damages of whatever kind, which may, at any time, result to me, my heirs, family, or associates because of compliance with this authorization and request to release.
Signature
*
Date of Signature
*
-
Month
-
Day
Year
Date
Submit
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