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Applicant Authorization and Consent For Release & Disclosure


We truly welcome your application for employment with CHRM. We are proud of our success and recognize it is the result of the quality and caliber of the employees in our organization. In pursuit of that excellence we require, as a condition of employment, and/or continued employment, that all applicants consent to and authorize a pre-employment verification of the background information submitted on their application and resumes.

This release and authorization acknowledges that this company and CHRM, a consumer reporting agency, may now, or at any time while you are employed, administer testing instruments, conduct and retrieve a verification of your education, previous employment/work history, credit record, contact personal references, require that you provide a urine/breath/blood specimen to be tested for the presence of drugs or alcohol, access motor vehicle records, worker’s compensation records and to receive any criminal history record pertaining to you which may be in the files of any federal, state, county or local criminal justice agency in any State and/or other information deemed necessary to fulfill the job requirements. The information received may include, but may not be limited to the aforementioned agencies. The results of this verification process will be used to determine employment eligibility. Convictions for a felony or misdemeanor will not necessarily be a bar to employment.

I authorize Creative Human Resource Management of Marietta, Georgia (referred to as "CHRM") and any of its agents/designated representatives to disclose orally, electronically, and in writing the results of this verification process and/or interview to the designated authorized representatives of this Company.

I do hereby forever release and discharge the Company, its agents, CHRM and its associates to the full extent permitted by the law from damages, losses, liabilities, costs and expenses, or any other charge of complaint filed with any agency arising from the retrieving and reporting of information. According to the Federal Fair Credit Reporting Act, I am entitled to know if adverse action is taken based on information obtained by the Company and to receive, orally, written or electronically, a copy of the consumer report and a description of the rights of a consumer. I agree that any copy of this document is as valid as the original.

NOTE: The following information is provided by you voluntarily and IS NOT considered to be a part of your application for employment. It is used for identification purposes to verify information you provided on you application. 


First Name:   Middle Name:   Last Name: 
Suffix:      Maiden Name: 
Social Security Number:      Date of Birth: 
Sex:     Race: 
Current Address: 
City:      State:      Zip: 
Time at Address: Years:	     Months: 
Please list other states you have lived in within the past 10 Years.
CityStateZipYearsMonths
1.
2.
3.
4.
5.
6.
7.
8.

Employment


Number of Previous Employers In the last 10 Years.
0
1
2
3+

1. Name of Employer:   May We Contact: 
   Address: 
   City:      State: 
   Contact:      Contact Phone: 
   Contacts Position/Department: 
   Position:   Employment Dates:  To: 
   Name used: 

1. Name of Employer:    May We Contact: 
   Address: 
   City:      State: 

   Contact:      Contact Phone:  
   Contacts Position/Department: 
   Position:   Employment Dates:  To: 
   Name used: 

2. Name of Employer:    May We Contact: 
   Address: 

   City:      State: 
   Contact:      Contact Phone:  
   Contacts Position/Department:  
   Position:   Employment Dates:  To: 
   Name used: 

1. Name of Employer:    May We Contact: 
   Address: 
   City:      State: 

   Contact:      Contact Phone:  
   Contacts Position/Department: 
   Position:   Employment Dates:  To: 
   Name used: 

2. Name of Employer:    May We Contact: 
   Address: 

   City:      State: 
   Contact:      Contact Phone:  
   Contacts Position/Department:  
   Position:   Employment Dates:  To: 
   Name used: 

3. Name of Employer:    May We Contact: 
   Address: 

   City:      State: 
   Contact:      Contact Phone:  
   Contacts Position/Department:  
   Position:   Employment Dates:  To: 
   Name used:

Education

1. Name of College:
   City:      State:       Graduated: 
   School Phone Number: 
   Degree:      Major:  
   Attendance: Start:      End: 
   Name used while at school: 

2. Name of College:
   City:      State:      Graduated: 
   School Phone Number: 
   Degree:      Major:   
   Attendance: Start:      End: 
   Name used while at school:

MVR

Name as it appears on Drivers License:

Drivers License No.:      State:

Professional License

Type of Professional License:

Professional License No.:      State: 


Electronic Signature:           Date:

Phone Number:

I have read, I understand and agree to each of the disclosures, authorizations, directions and
indemnifications. The typed version of my name is being accepted as my original signature pursuant
to the Georgia Electronic Records and Signature Act.

If you want a printed copy please print the form BEFORE you submit it.