EAST WAKE ACADEMY
RELEASE FORM FOR BACKGROUND CHECK
I, the undersigned, understand that investigative background inquiries are to be made on myself including consumer, criminal, driving and other reports. These reports will include information as to my character, work habits, performance and experience along with reasons for termination of past employment from previous employers. Further I understand that you will be requesting information from various Federal, State and other activities relating to my driving, credit, criminal, civil, and other experiences as well as claims involving me in the files of insurance companies.
I authorize, without reservation, any party or agency contacted by East Wake Academy to furnish the above-mentioned information.
A photocopy, or any other copy, of this instrument bearing my signature shall be equally legally valid as the original.
PRINT FULL NAME______________________________________________________
LAST FIRST MIDDLE
MAIDEN NAME OR “AKA”_______________________________________________
DATES USED: FROM______________________ TO___________________________
SOCIAL SEC. #________/________/_________DATE OF BIRTH**_______________
CURRENT ADDRESS_____________________________________________________
CITY/STATE/ZIP_________________________________________________________
DRIVER’S LICENSE #_________________________________STATE_____________
Please list all addresses you lived at for the past ten (10) years. Include the year you moved to this address and the year you moved out.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
APPLICANT’S SIGNATURE_______________________________________________
DATE____________________WITNESS______________________________________
**Date of Birth is being requested in order to obtain accurate retrieval records.