Information City

*** ************ ****., ***. ***, Charlotte, NC **273 704-***-****

**Fax completed form to 704-***-**** or send to ****@**********************.***** PERSONAL INFORMATION RELEASE FORM

Company

Last Name First Name Middle Name

Maiden Name / Other Names / Aliases Sex/ Race

Date of Birth Social Security Number

Driver’s License Number State Phone #:

Current Street Address

City State Zip Code

Please list any additional addresses residences in the last 7 years (most current first). Street Address

City State Zip Code

Street Address

City State Zip Code

I,, hereby authorize Employment Screening, Inc., and all their associated agencies, partners, or other entities (hereafter referred to as ESI) to secure any and all personal information from any source of record that they deem necessary in order to perform a background check on me. I further authorize ESI to release said information to any person and/or company with which this form has been filed, including their agents, and release all of the aforementioned companies, agents, and entities from any and all legal liability for collecting, furnishing or otherwise reporting the personal background information of the applicant/employee/candidate above. Applicant / Employee / Candidate Signature Date

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