Demo Company Electronic Consent Form Employee Candidate AuthorizationFederal Disclosure of Intent to Obtain Consumer Reports or Investigative Consumer Reports "Consumer reports" are reports from consumer reporting agencies and may include driving records, criminal records, etc. For such employment purposes, the Company may also obtain investigative consumer reports. Some reference checks by a consumer reporting agency fall into this category. An "investigative consumer report" is a consumer report in which information as to character, general reputation, personal characteristics, or mode of living is obtained through personal interviews with neighbors, friends, associates, acquaintances, or others. You have a right to request: (i) disclosure of the nature and scope of the investigation requested, (ii) a written summary of consumer rights, and (iii) a copy of such report. AUTHORIZATION I authorize the Company to obtain and release consumer reports and/or investigative consumer reports, including criminal reports, regarding me from time-to-time for employment purposes. All fields are required. If a section does not apply, please type none or n/a. Today's Date* MM slash DD slash YYYY Company IdentificationCompany Name*Select the business location that is considering you for employment.Select OneDemo Company 123Demo Company ABCOtherCandidate IdentificationName* First Middle Last Suffix Maiden name List any other names (name change, assumed name, nickname, etc.) which you may have used, and which will be necessary to verify prior to your employment:Email* Cell Phone*Personal IdentificationDate of Birth* MM slash DD slash YYYY Social Security Number* Confirm Social Security Number* Driver's License Number* Driver's License State* Other Driver's License held in past 5 years* Gender* Race* PROVIDE YOUR FULL RESIDENTIAL ADDRESS HISTORY FOR THE LAST 7 YEARS(CANNOT BE A PO BOX)Current AddressStreet* City* State* Zip Code* How long have you lived at this address?* Less than 7 years More than 7 years Previous AddressesPrevious Address #1* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code How long did you live at previous address #1?* Previous Address #2 Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code How long did you live at previous address #2? Previous Address #3 Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code How long did you live at previous address #3? Identity VerificationUpload Driver's License*Accepted file types: jpg, gif, png, pdf, Max. file size: 128 MB.Upload Social Security CardAccepted file types: jpg, gif, png, pdf, Max. file size: 128 MB.CommentsThis field is for validation purposes and should be left unchanged. Δ Please call SecureHire at 678-527-1909 if you have any problems related to this consent form.