Application for Employment
* Indicates Required Information

Background Investigation Check List
 
* Turnaround Time:   5 Business Days  3 Business Days  24 Hours
 
1 - Education/Degree Verification
 
College: 
High School: 
 
Other #1: 
 
Other #2: 
 
2 - Employment Verification
 
All employment in past five years?: Yes
No
If not, please specify here, or on application/resume:
 
3 - References
 
Yes   No If yes, please specify names and phone numbers here, or on application/resume
Reference #1 Name: 
  Phone #: 
Reference #2 Name: 
  Phone #: 
Reference #3 Name: 
  Phone #: 
Reference #4 Name: 
  Phone #: 
 
4 - Credit Report
 
(Requires candidate's signed release authorizing credit in particular, plus a separate disclosure to candidate)
Yes   No
 
5 - Criminal Records Search
(May require date of birth; list here if available)
Yes   No   DOB 
6 - Motor Vehicle Records Search
(Requires license # and date of birth)
Yes  No  License #   DOB 
7 - Worker's Compensation
(Requires city and state)
Yes  No  City   State 
8 - Professional Licenses
(Requires license type)
Yes  No
License Type #1 
License Type #2 
Application for Employment
* Recruiter Name: 
* Company Name: 
Today's Date: 
* Social Security Number: 
* Name (First, Last): 
Maiden Name: 
* Address 1: 
* City: 
* State/Province: 
Country: 
* ZIP Code: 
Address 2: 
City: 
State/Province: 
Country: 
Zip Code: 
* Phone Number: 
* E-Mail Address: 
Emergency Contact: 
Emergency Phone Number: 
Education History
* School #1 
* Address 
* Dates Attended   to  
* Major 
* Degree 
School #2 
Address 
Dates Attended   to  
Major 
Degree 
School #3 
Address 
Dates Attended   to  
Major 
Degree 
 
Drivers License Information
License Number 
State 
Date of Birth 
** Drivers Information should be filled in if this information is appropriate to your application.
 
Previous Employment History
Include all employment for the last ten years beginning with the most current. For additional employment within the last five years please fax resume.
* Employer / Company #1 
Company Phone Number 
Company Address 
* City 
* State 
* Zip Code 
Supervisor 
Weekly Hours Worked 
* Your Job Title 
Your Job Duties 
* Employment Dates    to  
* Wage / Salary  per 
* Reason For Leaving 
Employer / Company #2 
Company Phone Number 
Company Address 
City 
State 
Zip Code 
Supervisor 
Weekly Hours Worked 
Your Job Title 
Your Job Duties 
Employment Dates    to  
Wage / Salary  per 
Reason For Leaving 
Employer / Company #3 
Company Phone Number 
Company Address 
City 
State 
Zip Code 
Supervisor 
Weekly Hours Worked 
Your Job Title 
Your Job Duties 
Employment Dates    to  
Wage / Salary  per 
Reason For Leaving 
Employer / Company #4 
Company Phone Number 
Company Address 
City 
State 
Zip Code 
Supervisor 
Weekly Hours Worked 
Your Job Title 
Your Job Duties 
Employment Dates    to  
Wage / Salary  per 
Reason For Leaving