Employment Form

WORK HISTORY

Are you currently employed?

May we contact your current employer?

EMPLOYER I

Position

Job Description

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Month & Year

Salary

Phone Number

Area CodePhone Number

Reason for Leaving

_______________________________________________________________________________________

EMPLOYER II

Position

Job Description

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Month & Year

Salary

Phone Number

Area CodePhone Number

Reason for Leaving

_______________________________________________________________________________________

EMPLOYER III

Position

Job Description

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Month & Year

Salary

Phone Number

Area CodePhone Number

Reason for Leaving

Pleaase explain any gaps in your employment

Please verify that you are human

I hereby authorize and request any and all my former employers and any other person, firm or corporation to furnish any and all information concerning credit-worthiness and personal background and I hereby release each such employer or other person, firm or corporation from any and all liability by reasons of furnishing the requested information. I understand that in connection with this application, a consumer report and / or an investigative consumer report may be requested whereby information is obtained through personal interview with my neighbors, friends or associates or with others with whom I am acquainted or who may have knowledge with respect to my character, general reputation, personal characteristics and mode of living, and hereby authorize the procurement of any such report. I understand that, upon my request, I have the right to know if any such report was requested and, if so, the name and address of the consumer reporting agency that furnished such reports and in the case of a consumer investigative report, that I may inspect and receive a copy of such report by contacting such agency. I also understand that I have the right to receive a complete and accurate disclosure of the nature and scope of the information requested if I request such disclosure within a reasonable period of time.I understand that if employed any misrepresentation or omission of facts requested is cause for dismissal.