BACKGROUND CHECK RELEASE I hereby authorize Entrusted Transport, LLC. and it's 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 Entrusted Transport LLC. or its agents. I further authorize the complete release of any records or data pertaining to me which the individual, company, firm, corporation, or public agency may have, to include information or data received from other sources. Entrusted Transport, LLC. and its designated agents and representatives shall maintain all information received from this authorization in a confidential manner in order to protect the applicants personal information, including, but no limited to addresses, social security numbers, and dates of birth. Name * First Name Last Name May your current employer be contacted? Yes No Not currently employed Post hire only California, Minnesota, or Oklahoma - Are you employed in, seeking employment in or a resident of one of these states? If so, do you wish to receive a copy of any Consumer Report of which you are the subject of? Yes No I have read, understand, and agree to the above statement. Yes No Date of Birth MM DD YYYY Birth Place Social Security Number Please list any other last name under which you received your GED, High School Diploma or other academic credentials: Weight Eye Color Hair Color What is your height? In what other states have you lived after 18 years of age. I understand that the employer has the right to proceed with any criminal background check. Yes No I understand that the employer has the right to review my motor vehicle report. Yes No I understand that I may be required to have a physical examination and I hereby consent to take a physical examination and any future physical examinations as required by the employer. Yes No I understand that if I am hired I will be required to produce proof that I have a legal right to work in the U.S.A. in accordance with the IRCA of 1986. Yes No I understand that this form is not an employment contract. Yes No I understand that a drug test is required for this position. Yes No Your information has been submitted to Entrusted Transport. Thank you!
