UNIVERSAL BACKGROUND SCREENING
Request Form
Date: Name: First Address: City: Date of Birth: Drivers License Number: Other Names Used (Maiden Names, AKA’s, etc): Please list the Zip Code for the address in the county which you have resided in the past (7) years. Limit one zip code per county. State: Social Security Number: State Issued: Zip Code: : Full Middle : Last

1. Zip Code: _____________ 2. Zip Code: _____________ 3. Zip Code: _____________
Combined Disclosure Notice and Authorization Regarding Investigative Consumer Reports I understand that as a condition of my consideration for employment, or as a condition of my continued employment, Dependable Staffing Services may obtain a consumer report and/or investigative consumer report that includes, but is not limited to: employment and education verifications; social security number verification; criminal and civil court records; personal interviews; driving records; and/or any other public records or any other information bearing on my character, general reputation, personal characteristics and trustworthiness. I hereby authorize and consent Dependable Staffing Services and/or its designated agent, to procure such a report. I understand that pursuant to the federal Fair Credit Reporting Act, Dependable Staffing Services will provide me with a copy of any such report if the information contained in such report is, in any way, to be used in making an adverse decision regarding my fitness for employment. I further understand that such report will be made available to me prior to any such adverse decision being made, along with the name and address of the reporting agency that produced the report. Applicant Signature: Date:

UNIVERSAL BACKGROUND SCREENING USE ONLY - APPLICANT DO NOT WRITE BELOW THIS LINE

CUSTOMER #_________INPUT FORM
Please perform the following check marked screens only. √

NCIC / ACIC Warrants and Wants 39 - Month Driving Record

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Arizona Statewide Criminal History check Additional County (Zip’s Listed only) History check

Dependable Staffing Services . 3507 North Central . First Floor . Phoenix Arizona 85012 . 602.264.1444

IMPORTANT PLEASE COMPLETE Background Screening Form Questionnaire and Instructions

1.

Have you ever been convicted of, or have you pleaded guilty or no contest (nolo contendere) to, a felony offense? YES NO (Please check one)

(Answering "yes" will not automatically bar you from employment) If you answered Yes to question one, Please list the City and State the incident(s) was/were prosecuted in on the attached form where it asks for Zip codes you have resided in for the past 7 years. Please do this even if the event took place over Seven years ago. If you answered No to question one, please only list the Zip codes you have resided in for the past 7-years.

2.

3.

Combined Disclosure Notice and Authorization Regarding Investigative Consumer Reports I understand that as a condition of my consideration for employment, or as a condition of my continued employment, Dependable Staffing Services may obtain a consumer report and/or investigative consumer report that includes, but is not limited to: employment and education verifications; social security number verification; criminal and civil court records; personal interviews; driving records; and/or any other public records or any other information bearing on my character, general reputation, personal characteristics and trustworthiness. I hereby authorize and consent Dependable Staffing Services and/or its designated agent, to procure such a report. I understand that pursuant to the federal Fair Credit Reporting Act, Dependable Staffing Services will provide me with a copy of any such report if the information contained in such report is, in any way, to be used in making an adverse decision regarding my fitness for employment. I further understand that such report will be made available to me prior to any such adverse decision being made, along with the name and address of the reporting agency that produced the report.

I acknowledge the above questions to be true to the best of my knowledge and belief.

Applicant Signature:

Date:

Dependable Staffing Services . 3507 North Central . First Floor . Phoenix Arizona 85012 . 602.264.1444