I, the undersigned, hereby authorize Interstate Background Research, Inc.
acting as an agent for __________________________________________ to receive any criminal
history record information pertaining to me, which may be in the files of any state or any
local criminal justice agency, or any law enforcement agency.
This request is valid for, but is not limited to the States of Georgia, and Iowa
This request/release is valid for one (1) year from this date hereon.
NOTE TO CLIENT: This form must be submitted with the application (background request.)
FOR THE PURPOSE OF EXPEDITING YOUR REQUEST, A FACSIMILE COPY OF THIS FORM WILL BE REGARDED AS THE ORIGINAL.
Part A: To be completed by REQUESTOR for Company:
Signature of Requestor: ________________________________ ** SIGN HERE
Name and Title of Requestor: ______________________________________
Requestor Company Full Name: ______________________________________
Requestor Telephone Number: ___________________________________
PART B: To be completed by CANDIDATE: Request Date: ___/___/______
Candidate Social Security Number: _______-_____-________
*Candidate Date of Birth: ____/____/_______ *Gender: ________
Candidate Full Name: _______________________________________
Candidate Street Address: _______________________________________
Candidate City, State and Zip: ________________________________________
Signature of Candidate: ________________________________ ** SIGN HERE
THANK YOU* May be deemed necessary to conduct a thorough criminal record search in accordance
with the, "Code of Federal Regulations" Equal Employment Opportunity Commission
Code 1625.5.
* This request for your date of birth does not indicate discrimination; and the request in
itself is not a violation of the Age Discrimination Act. Your date of birth is requested
for a permissible purpose, under the code, and has been ruled a critical identifier for
criminal and driving history information. Some states will not conduct a criminal search
without the date of birth.
form crim_rel rev 08/19/1999