I wasa caregiver, cleaned and disinfected schools and factories for Co
Resume:
****- ****** ** - ************* & Consent for Release of Personal Information Rev 2018-10-22
AUTHORIZATION AND CONSENT FOR RELEASE
OF PERSONAL INFORMATION
This authorization and consent for release of personal information acknowledges that Malace HR
(known collectively as MALACE & ASSOCIATES, INC., MALACE INTERNATIONAL, LLC, MALACE FACILITIES SERVICES, LLC and LWM HOLDINGS, LLC.; and hereafter referred to as "Company" or
“MALACE HR”) and/or any other Company agent, investigator, or source, may now, or at any time I am assigned to or employed by this Company, conduct investigations whether the records are of a public, private or confidential nature. These investigations might include, but are not limited to, searches of education institutions attended; financial or credit institutions, including records of loans; records of commercial or retail credit agencies; other financial statements; records of previous employment, including work history, efficiency ratings, complaints and grievances filed by or against me; records and recollections of attorneys-at-law or of other counsel whether representing me or any other person (in either a civil or criminal case in which I have been involved); records from the U.S. Veterans' Administration; criminal history information on file in local, state or federal agencies; and motor vehicle records, and following an employment offer, medical information and records, including history, examination, tests, diagnosis, prognosis, and treatment; workers' compensation reports from either the Department of Labor, National Personnel Records or the Industrial Commission or similar agencies under the provisions of the Fair Credit Reporting Act 15 USC _1681, et seq. I also authorize any custodian of my military service records to release to MALACE HR and/or its duly appointed agent my military service record, including DD214 and all service records, including any disciplinary records. In addition, if an international search is needed, I agree that, in accordance with host national laws regarding the release of information, the data protection privacy act, the European privacy act and others, I authorize the release and transmittal of information from any country to MALACE HR and/or its agents, including, but not limited to, our designated agents and information sources for satisfying the purposes of this background check, and to any person, entity, client, customer, placement, employer, or prospective placement where I will or may be placed for service.
I understand that these searches will be used to determine work assignment or employment eligibility under the Company's employment policies. Therefore, I authorize and consent for full release of records
(either orally or in writing) to the authorized representatives of the Company. I further authorize MALACE HR to furnish a copy of a report received to its customer to whom I will be assigned during the course of my employment with the company. In addition, I release and discharge the Company and its agents and associates to the full extent permitted by law from any claims, damages, losses, liabilities, costs, expenses or any other charge or complaint filed with any agency arising from retrieving and reporting this information. These releases and authorization(s) shall remain valid and in effect during the term of my relationship with MALACE HR, and MALACE HR reserves the right to obtain subsequent consumer reports and/or investigative consumer reports on an as-needed basis. I understand that according to the Federal Fair Credit Reporting Act, I am entitled to know whether employment was denied based upon the information obtained and to receive, upon written request, a disclosure of the background report. I also understand that if I would like further information about the nature and scope of the requested investigation, I may furnish a written request to MALACE HR, Attn: Human Resources at 5700 Crooks Rd., Suite 112, Troy, MI 48089. After reading this document, I fully understand its contents and authorize the background verification, and the release of such investigation and information to any person, entity, client, customer, placement, employer, or prospective placement where I will be or may be placed for service. All employment is at-will, subject to the terms of the Company employee handbook. Incomplete or inaccurate entries subject the candidate to discharge as discovered during employment. 0003- Malace HR - Authorization & Consent for Release of Personal Information Rev 2018-10-22
(Continued on Page 2)
AUTHORIZATION AND CONSENT FOR RELEASE
OF PERSONAL INFORMATION
(Page 2)
Do you reside in California, Minnesota or Oklahoma? yes no If so, do you want a copy of any Consumer Report
prepared concerning you? yes no
I understand that California law requires Company to give me a copy of any report requested within seven (7) days of the date the information was obtained and that failure to do so will expose Company to liability (Section 1786.29).
(List all cities and states where you have lived for the past 7 years) Attach additional sheet if necessary.
Street City County State Zip How Long?
Current: 2. 3. 4. Present Phone Number: / Social Security Number: Date of Birth (for Identification Purposes only): Sex: Male: Female: Driver's License Number: State: Printed Name: First Middle Last
Maiden Name: Other last names used: Signature: Date: IL
9719 Rambouillet rdg
9719 Rambouillet rdg
Machesney Park
03/01/1984
402 Marquette Rd
370946758
Lauren
X
Kupkowski
15 years
15 years
61073
61073
5 years
Ashley
X
IL
IL
Kupkowski
Winnebago
Winnebago
Winnebago
IL
61115
Roscoe
Roscoe
K122-0128-4663
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