Bearak Reports Background Search Authorization Form


I, hereby authorize ________________________________. Itís subsidiaries, affiliates, employees and agents, including the credit bureaus, to make inquiries of and request information from any individuals, present and former employers, schools and colleges, credit bureaus, criminal investigation bureaus and any other entities that may possess information concerning me or that may be custodians of records relating to me, including Workerís Compensation and Driving Records. I also authorize the above described sources to release all information requested, including salary data and subjective evaluations, and I hereby release those sources from any liability for doing so.

I give this authorization in connection with an application/resume relating to employment.

Applicantís Signature:___________________________________________________

Name (please print):_____________________________________________________

Current Address:_____________________________________Dates:_____________

Previous Address:____________________________________Dates:_____________

Social Security #: __________ - _______ - __________

Date of Birth: __________ / __________/ __________
(to be furnished for criminal record and driving record checks)

Driverís License #: _________________________________ State:______________

Please fax this signed Authorization Form
to BEARAK REPORTS at 508-788-6642.