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RELEASE OF LIABILITY/CONSENT FORM

I am aware that any omission, misstatement, misrepresentation, or falsification on my application may disqualify me for employment or contract consideration, and if I am hired/contracted, that may be grounds for termination at a later date.

I understand that any information that I provide may be verified as allowed by law. I authorize the procurement of a credit report. I also authorize all persons and entities (including but not limited to: former employers and supervisors; businesses; corporations; credit reporting agencies; law enforcement agencies, including the State of Georgia; government agencies; educational institutions; and, all military services) to release all verbal and written information regarding my ability and fitness of consideration of employment/contract.

I hereby authorize Interstate Background Research, Inc. to receive any criminal history record, pertaining to me, found in the files of any law enforcement or criminal justice agency.

I hereby release each individual and each company from all liability, and from all responsibility for providing said information and/or records, both written and/or verbal.

I realize that public record information may not be 100% accurate, and that I may be required to submit a fingerprint card for positive identification.

____________________________________________
Your Full Name, typed or printed

____________________________________________
Your Address

____________________________________________
Your Address

________             ____________           ___/___/_____
*Gender                      *Race                     Date of Birth

_______/_____/________
  Social Security Number

___________________________________________
Your Signature

* 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.

* The request for your date of birth does not indicate discrimination and the date request in itself is not a violation of the, "Age Discrimination Act." Your date of birth is requested for a permissible purpose and has been ruled a critical identifier for criminal and driving history information. Certain states will not conduct a criminal search without the date of birth.

Click HERE to view the text of the Equal Employment Opportunity Commission Code Sec. 1625.5

Click HERE for a printer friendly version of this form.

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FOR INFORMATION FROM IBRInc
PLEASE CONTACT:

IBRInc
Post Office Box 817
New Port Richey, Florida  34656-0817
Telephone: (727) 944-5888
Toll-Free: (800) 994-1100
Fax: (727) 944-5828
e-mail: sales@ibrinc.com
License #A9600263

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