Background Release Form

Background Release Form

Please complete this form in its entirety.
Full Name*

First NameLast Name
Middle Initial
Maiden Name
Social Security Number (no dashes)*
Email
example@example.com
Date of Birth*

MonthDayYear
Date
Address*

Street Address

CityState / Province

Postal / Zip Code
Please list any other counties you have lived in outside of TN in the last 7 years.*
Employee Authorization to Release Records

I understand and agree that: The information supplied, was submitted by myself, and all information is true and correct, to the best of my knowledge. I understand that false or misleading information given in my application and/or interview(s) will be considered as cause for termination. I also understand that I am to abide by all rules and regulations of the organization.

The company has my authorization to thoroughly investigate my work and personal history. I understand that the information supplied by me, regarding my: Employment History, Education (including an authorization to release transcripts, if applicable), Criminal History, Motor Vehicle Record(s), Residence History, and References will be utilized as part of the processing procedures. A background check will be conducted to verify the veracity of the information submitted and will be utilized to develop information concerning my character, general reputation, personal characteristics, and mode of living. I will hold no person liable for giving or receiving information in this investigation.

I hereby authorize Blue Line Investigations an agent of Ballet On Wheels to make a thorough check of my past Employment, Education, and activities.

I release from liability all persons, companies, and corporations supplying that information.

I release and indemnify Ballet On Wheels and Blueline Investigations against any liability that might result from this Background Check. A copy of this form is valid as the original.
Applicant E- Signature*

First NameLast Name
Date*

MonthDayYear
Date
Should be Empty: