Background Check Attestation Form

Background Check Attestation Form

Please fill out your personal details and sign the form to confirm your background check acknowledgment.
Full Name (as named at birth)

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Date
Social Security Number
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Current Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Attestation Statement
I hereby authorize the company to conduct a criminal background check, employment verification, and any other necessary screening as part of the employment process. I understand that the information obtained may be used to determine eligibility for employment. I certify that all information provided by me is true, complete, and accurate to the best of my knowledge. I understand that any false, misleading, or incomplete information may result in denial of employment or termination of employment. I further acknowledge and agree that if I voluntarily resign, quit employment, or am terminated for cause within ninety (90) days of hire, the cost of the background check may be deducted from my final paycheck to the extent permitted by state and federal law. I understand that continued employment is contingent upon satisfactory background screening results and compliance with company policies and procedures.
Signature
Should be Empty: