Palmetto Compliance & Testing | Background Screening Disclosure & Authorization
This form provides important information regarding the background screening requested through Palmetto Compliance & Testing and documents your authorization for applicable screening to be conducted. Please review all information carefully before providing your electronic signature.
Requestor Information
Who is requesting this background screening?
*
Individual requesting a screening for myself
Employer / Business
Organization
Authorized Representative
Other
Requestor Full Name
*
First Name
Last Name
Company | Organization Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Person Being Screened
Full Legal Name
*
First Name
Middle Name
Last Name
Date of Birth
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Background Screening Information
What is the Purpose of this Background Screening
*
Employment / Pre-Employment
Contractor / Vendor Screening
Volunteer Screening
Personal / Self-Requested Background Check
Driver / Motor Vehicle Screening
Licensing / Credentialing
Other
Employer | Organization Name
Background Screening Information
Which screening service(s) are your interested in?
*
Criminal Record Screening
Motor Vehicle Record (MVR)
Employment Verification
Identity / SSN-Based Search
Professional License Verification
Sex Offender Registry Search
Employment Screening Package
Drug Testing + Background Screening
Custom Screening Package
Not Sure - I Need Assistance
Additional Information
Number of individuals to be screened?
1
2-5
6-10
11+
Is this a one-time screening or are you interested in ongoing screening services?
One-time
Ongoing employer screening services
Not sure
Additional Information / Special Requests
Request Acknowlegment
Background Screening Request Acknowledgement
*
I understand that submitting this form is a request for background screening services and does not by itself authorize Palmetto Compliance & Testing or its screening provider to obtain a consumer report. Additional information, disclosures, authorization, identification, and/or documentation may be required before screening can begin.
Communication Preferences
Contact Consent
I authorize Palmetto Compliance & Testing to contact me regarding this background screening request using the contact information provided on this form.
Date Signed
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Background Screening Request
Should be Empty: