Full Legal Name *

Please give your legal first and middle name under "First Name" and last name under "Last Name."

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Consumer's Signature *

By typing my name below, I am authorizing this as my legal signature. As such, I am authorizing that the information given above is accurate and complete. *This information will be used for background screening purposes only.

First Name

Last Name

Today's Date *

MM

DD

YYYY

Minnesota and Oklahoma Applicants or Employees only:

As stated above, please check this box if you would like to receive a copy of a consumer IF one is obtained by the Company

Name

First Name

Last Name

1. Have you ever been convicted or plead guilty before a court of any federal, state, or municipal criminal offense? *

(Excluding minor traffic violations)

Yes

No

2. Have you ever received deferred adjudication or similar disposition for any federal, state, or municipal criminal offense? *

Yes

No

3. Have you ever received probation or community supervision for any federal, state or municipal criminal offense? *

Yes

No

4. Have you ever been convicted of any criminal offense in a country outside the jurisdiction of the United States? *

Yes

No

5. As of the date of this authorization, do you have any pending criminal charges against you? *

Yes

No

6. Have you ever served in the US Military? *

Yes

No

7. If you answered YES to the above question, did you receive a DD214?

Yes

No

If Yes, can you present the document?

Yes

No

8. If you answered YES to the above Question 6, did you receive an honorable discharge?

Yes

No

Consumer Signature *

By typing my name below, I am authorizing this as my legal signature.

First Name

Last Name

Today's Date *

MM

DD

YYYY