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Background Check Authorization
I Agree To Background Check Authoriztion
(Required)
YES
RAD ID#
(Required)
Get Your RAD By Visiting www.lifelinerad.org And Clicking Register.
Name
(Required)
First
Middle
Last
Former Name(s)
Dates Used
(Required)
MM slash DD slash YYYY
Current Address Since:
Date(Mo\Yr)
(Required)
MM slash DD slash YYYY
Street
(Required)
City
(Required)
Zip/State
Previous Address From
Date(Mo\Yr)
(Required)
MM slash DD slash YYYY
Street
(Required)
City
(Required)
Zip/State
(Required)
Previous Address From:
Date(Mo\Yr)
(Required)
MM slash DD slash YYYY
Street
(Required)
City
(Required)
Zip/State
(Required)
Social Security Number
(Required)
Date of Birth:
(Required)
MM slash DD slash YYYY
Telephone Number
(Required)
Driver’s License Number/State
(Required)
Email
(Required)
Enter Email
Confirm Email
Shirt Size
(Required)
Banner
(Required)
Yes
No
The information contained in this application is correct to the best of my knowledge
(Required)
True
By signing below:
(Required)
I hereby authorize American Assistance (the “Company”) and its designated agents and representatives to conduct a comprehensive review of my background causing a consumer report and/or an investigative consumer report to be generated for employment and/or volunteer purposes. I understand that the scope of the consumer report/ investigative consumer report may include, but is not limited to the following areas: verification of social security number; credit reports, current and previous residences; employment history, education background, character references; drug testing, civil and criminal history records from any criminal justice agency in any or all federal, state, county jurisdictions; driving records, birth records, and any other public records. I further authorize any individual, company, firm, corporation, or public agency to divulge any and all information, verbal or written, pertaining to me, to or its agents. I further authorize the complete release of any records o r data pertaining to me which the individual, company, firm, corporation, or public agency may have, to include information or data received from other sources. and its designated agents and representatives shall maintain all information received from this authorization in a confidential manner in order to protect the applicant’s personal information, including, but not limited to, addresses, social security numbers, and dates of birth. I understand that any false answers or statements, or misrepresentations by omission, made by me on this application or any related document, will be sufficient for rejection of my application or for my immediate termination should such falsifications or misrepresentations be discovered after I am hired.
(Required)
SIGN YOUR NAME HERE
Date
(Required)
MM slash DD slash YYYY
