Consent for Background Check

Consent for Background Check

As part of the employment and placement process, Main Street Dental Staffing may obtain background information about you for employment-related purposes. By signing below, you authorize Main Street Dental Staffing and its authorized background screening provider to obtain information about you, where permitted by law, from sources that may include courts, law enforcement agencies, corrections agencies, public records, and other appropriate sources.Please complete all required fields.
Full Legal Name

First NameLast Name
Gender
Current Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Other Names Used (maiden, alias, or legal name change)
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Driver’s License Number
Driver’s License State
Previous Addresses (County/State OUTSIDE of Oregon) in past 7 years
Authorization

I certify that the information I have provided is true and complete to the best of my knowledge.I authorize Main Street Dental Staffing and its authorized background screening provider to verify the information I have provided and to obtain background information about me for employment and placement purposes, as permitted by applicable law.I understand that a copy or electronic version of this authorization may be accepted as valid as the original.
Signature of applicant
Signature of witness
Date

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

Authorization