Permission to Procure Background Check

Catholic Community Services of Lane County
1025 G Street | Springfield, OR 97477
541-345-3628 | www.ccslc.org
Permission to Procure Background Check

Please complete the entire form
Full Legal Name

First NameFull Middle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Email
example@example.com
Social Security Number
Numbers only, no spaces or characters
Driver's License or ID#
State
Expiration Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Other Names Used:
List the CITIES where you have lived during the past 7 years:
City / State
City / State
City / State
City / State
Have you EVER been convicted of a crime?

If yes, please provide details and locations of all convictions:

Rows	Crime	Date	City / State
1
2
3
4

INVESTIGATIVE CONSUMER REPORT AUTHORIZATION
In connection with my application I understand that an investigative consumer report may be requested that may include information regarding my court records both civil and criminal, my driving records, educational and professional credentials and personal and professional references. This may come from either public or private sources and may contain information regarding my character, experience, work habits and reasons for termination from past employers. I understand that this document shall be kept on file and may be used at any time during my employment to procure an investigative report. I hereby release and discharge to the extent permitted by law, Catholic Community Services of Lane County, Inc., its employees, any individual or agency obtaining information for Catholic Community Services of Lane County, Inc., my personal and professional references, and my former employers, from any and all claims known or unknown, damages, losses, liabilities, cost, or other expenses arising from the retrieving, reporting and/ or disclosure of information in connection with this background investigation. I also understand that I may (1) request in writing the nature of the information obtained and (2) request a written summary of my rights under the Fair Credit Reporting Act. I hereby agree that a photographic copy, a telephonic facsimile, or an electronic copy of this document shall be valid for all purposes present and future. I have read, understand, and agree with the above.

I certify that the information provided is accurate and understand that my electronic signature below is my legal and binding signature.
Print Name
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Should be Empty: