EMPLOYMENT SCREENING QUESTIONAIRE

USA INVESTIGATIONS, LLC

6750 NORTH ANDREWS AVE, SUITE 200

FT. LAUDERDALE, FL 33309
The USA Investigations client questionnaire is for individuals who are seeking a background screening. You will need to complete both forms and answer all questions. Please note that some of the questions are repetitive. If any of the questions do not pertain to you, enter N/A in that section. Once you complete the form you will receive a copy of your answers for your review. You will also have an opportunity to preview your responses before submitting your form. To preview the form, click on the preview tab at the end of the form. To return to the form, click on the “Return to Form tab at the top of the first page.
Date*

MonthDayYear
Date
USA INVESTIGATIONS LLC
Controlling Agency Identifier (ORI #)
Reason Screened*
First Name*
Middle Name*
Last Name*
Date of Birth*

MonthDayYear
Date
PLACE OF BIRTH: (Enter City, State if born in USA ; Enter name of country if outside the USA)*
CITIZENSHIP: (If United States Citizen enter that below if not a US citizen enter country of citizenship*
Social Security #*
Height*
Weight*
Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
Gender*

MaleFemaleOther/Unknown
Race*

AsianBlackNative AmericanCaucasian/ LatinoUnknown/ Other
Eye Color*

BlackBlueBrownHazelGreenGrayMulti-Color
Hair Color*

BaldBlackBrownBlonde/StrawberryGray/PartialWhiteSandyRed/Alburn
USA INVESTIGATIONS, LLC

6750 N ANDREWS AVE, SUITE 200

FT. LAUDERDALE, FL 33309

DISCLOSURE/AUTHORIZATION FOR RELEASE OF INFORMATION FOR EMPLOYMENT PURPOSES-Bacgroun Screening Disclosure

DISCLOSURE

By this document the facility discloses to you that a consumer report or investigative Consumer Report may be obtained for employment purposes as part of our employment screening process and at any time during your employment with our company. This shall authorize the procurement of a consumer report by the facility as part of the employment background screening process. If hired, this authorization shall remain HCL on file and shall serve as an ongoing authorization for the facility to procure consumer report at any time during my employment. The background check company USA Investigations will prepare the report for the company. USA Investigations is located at 6750 N Andrews Ave, Ft. Lauderdale, Florida 33309 and can be reached by phone at 954-778-3932 or at their internet website address http://www.usainvestigations.us.

Authorization

I also authorize the procurement of a consumer report for an investigative consumer report and understand that it may contain information about my criminal history, driver's history, mode of living, character and personal reputation. I hear my authorized the release of all information to USA training academy and investigative services. I understand that I have the right to obtain additional disclosure as to the nature and scope of the investigation upon written requests with a within a reasonable period of time and to obtain a copy of the report upon request. This authorization, an original or copy former, shall be valid for this and any future report or update that may be requested.

This authorization and concent shall be valid in origina, fax, or copy form. The following information is requeied by law enforcemment agencies and other entities for identification purposes when checking records. I is confidential and will be used for any other purpose.

** Asummary of Your Rights under the Fair Credit Reporting Act is also being provided to your with this form.
*** California, Minnesota, Massachusetts, Washington State, New York, New Jersey, and Oklahoma Applicants: Please check below to have a copy of your consumer report e-mailed directly to you***

Type option 1
Notice to Maine Applicants: Under Chapter 210, Section 1314 of Maine Revised Statutes, you have the right to be informed within 5 business days of a request for an investigative consumer report whether or not one was requested. If such a report was obtained, you may contact the Consumer Reporting Agency and request a copy.
Applicant's Name*
Maiden/AKA/Previous*
Social Security Number*
Date of Birth (This will not affect hiring decision)*

MonthDayYear
Date
Drivers or Non-Drivers License # *
State of Insurance (Enter N/A if you do not have auto insurance)*
Current & Prior Address History: (Please provide your addresses for the past seven (7) years If more space is needed, please enter in the space provided at the end of this application. *
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: