BACKGROUND CHECK AUTHORIZATION FORM


(THIS SECTION TO BE COMPLETED BY HIRING UNIT)

Return results to:___________________________________________

Prospective:   _______________________________________________

Supervisor:  _________________________________________________

Vacant Position Title  __________________________________________


- - - - - - - - - - - - - - - - - THE REMAINDER OF THIS FORM TO BE COMPLETED BY THE APPLICANT - - - - - - - - - - - - - - - - -


Last Name, First Name, Middle Name___________________________________________________________

Maiden Name:  ____________________________________________

Other name(s) used:  _______________________________________________________________________

Date of birth:  ______________________________________

SSN:**  ___________________________________________

Street Address:  ____________________________________

City, State   ________________________________________        Zip Code:  __________________


** To be used solely for the purpose of conducting a background check.

In connection with my application for employment and/or my continued employment, or in connection with my desire to engage in work as an independent contractor,
I have been advised and I hereby consent and authorize either Agency and/or its agent, at any time during my application process and/or employment/contract work,
to obtain an investigative background check that may include, but not be limited to, a criminal record check, employment and education verification and driving record.
I do hereby consent and authorize either Agency and its agent to use any information provided on this form or during the application process in obtaining the investigative
background report. I have been informed that I have the right to review and challenge any negative Information that would adversely impact me or adversely affect a
decision to offer employment. I agree to release, indemnify and hold harmless either Agency and any reporting agency used by Agency and/or its agent with regard to
any information reported by the background reporting agency. I understand that I am to be provided the name, address and telephone number of the background
reporting  agency and the nature and scope of the investigative report will be disclosed to me. I acknowledge that facsimile, copy or email of this document shall have
the same validity, force and effect as the original.

The following are my responses to questions about my criminal history, if any. (Exclude minor traffic offenses punishable only by fine. (IF YOU ANSWER YES TO ANY
OF THE FOLLOWING QUESTIONS, ATTACH DETAILS ON A SEPARATE SHEET OF PAPER TO INCLUDE THE STATE, COUNTY, DATE OF OFFENSE, AND DETAILS
OF THE CONVICTION).

1. Have you ever been convicted or pled guilty before a court for any federal, state or municipal criminal offense?
____Yes ____No
(If yes, attach an extra page with the details including state, county, date of offense and details of the conviction.)

2. Have you ever received deferred adjudication or similar disposition for any federal, state or municipal offense?
____Yes ____No
(If yes, attach an extra page with the details including state, county, date of offense and details of the conviction.)

3. Have you ever received pre-trial diversion or similar disposition for any federal, state or municipal offense?
____Yes ____No
(If yes, attach an extra page with the details including state, county, date of offense and details of the conviction.)

4. Have you ever received probation or community supervision for any federal, state or municipal offense?
____Yes ____No
(If yes, attach an extra page with the details including state, county, date of offense and details of the conviction.)

5. Have you been convicted of any criminal offense in a country outside the jurisdiction of the United States?
____Yes ____No
(If yes, attach an extra page with the details including state, county, date of offense and details of the conviction.)

6. As of the date of this consent form, do you have any pending charges against you?
____Yes ____No
(If yes, attach an extra page with the details including state, county, date of arrest and details of the arrest.)

LIST ALL COUNTIES AND STATES OF RESIDENCE SINCE HIGH SCHOOL GRADUATION OR AGE 18.  BEGIN WITH MOST RECENT (attach extra page if needed).

City__________________________________ County_________________________

State______________________

City__________________________________ County_________________________

State______________________

City__________________________________ County_________________________

State______________________

City__________________________________ County_________________________

State______________________

City__________________________________ County_________________________

State______________________

City__________________________________ County_________________________

State______________________

City__________________________________ County_________________________

State______________________

City__________________________________ County_________________________


(1)  I HEREBY CERTIFY THAT ALL INFORMATION PROVIDED IN THIS BACKGROUND CHECK DISCLOSURE NOTICE AND AUTHORIZATION FORM IS TRUE,
CORRECT AND COMPLETE. I UNDERSTAND THAT INCORRECT OR INCOMPLETE INFORMATION MAY BE GROUNDS FOR TERMINATION OF CURRENT
EMPLOYMENT OR CANCELLATION OF ANY AND ALL OFFERS OF EMPLOYMENT AT THE DISCRETION OF THE APPLICABLE AGENCY.

(2)  I UNDERSTAND APPLICANTS ARE REQUIRED TO REPORT ARRESTS MADE BETWEEN THE APPLICATION FOR EMPLOYMENT AND DECISION TO
HIRE THE APPLICANT FOR EMPLOYMENT.

(3)  I HAVE ATTACHED PAGES WITH DETAILS OF ARRESTS AND CONVICTIONS FOR ANY AND ALL “YES” RESPONSES TO QUESTIONS 1-6 ON THE
FIRST PAGE.

SIGNATURE OF APPLICANT OR EMPLOYEE  _______________________________________             DATE ___________________

PRINT NAME  _____________________________________________


APPLICANT CONTACT INFORMATION:

_________________________________________________________________
(Email address) (Phone number)


(This form should be returned to Alliance MT. Inc., Human Resources by email (mwade@alliancemt.com) or fax: 877-303-2284).

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