Release and Authorization Form

Release and Authorization Form

Release And Authorization To Obtain Consumer And/or Investigative Consumer Report
I, the undersigned, hereby consent, authorize and release On the Road Truck Repair & Services Inc., its affiliated companies, its subcontractors, and/or its agents (collectively, herein after referred to as the “Company”) to procure consumer reports on me including, but not limited to information concerning my character and general reputation. These reports may be obtained through, but not limited to the following sources: motor vehicle report, social security number verifications, present and former addresses, criminal and civil history/records, and any other public records.

I hereby release any and all persons, business entities, third party agencies, and governmental agencies providing information, whether public or private, from any and all liability, claims, and/or demands, by me, my heirs or others making such claims or demand on my behalf for providing consumer report(s) and/or investigative consumer report(s) authorized therein.

I authorize without reservation the Railroads, for which the Company provides services, to access my information in order to determine if I am eligible to preform work on their property.

Further, if I am selected as an employee, or an employee of an independent contractor, for the Company, I understand and authorize that periodic investigations may be requested for the duration of my association with the Company. I understand that this release and authorization shall remain in effect for the duration of my association with the company. Additionally, I hereby authorize the Company to investigate any incidents of workplace misconduct made against or involving me both during and after the term of my association with the Company.

I understand and agree that any information provided by me that is found to be false, incomplete or misrepresented in any respect in the Company’s sole judgement, will be cause to cancel further consideration of my application for employment and/or contracting services whenever such discrepancies are discovered. Further, I understand that by requesting this information that no promise of employment is being made. I am willing that a photocopy of this authorization will be accepted with the same authority as the original.

I HERBY CERTIFY THAT THIS FORM WAS COMPLETED BY ME, AND THAT THE INFORMATIN PROVIDED IS TRUE AND CORRECT AS OF THE DATE HEREOF.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Social Security Number*
Gender*

MaleFemale
Driver's License Number*
Issuing State*
Daytime Phone Number*
Other Names Used (alias, maiden, nickname)
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Are you applying for a position in California, Minnesota, or Oklahoma?*

YesNo
(If yes) Would you like a copy of any consumer reports requested sent to you?

YesNo
Signature

Clear
*Note: Date of Birth information is required for identification purposes only, and is in no manner used as qualifying for joining the Company. The Company does not discriminate on the basis of sex, religion, veteran status, age, or disability.
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