BACKGROUND CHECK AUTHORIZATION
Print Name: ________________________________________________________________
(First Name) (Middle Name) (Last Name)
Former Name(s) and Dates Used: _______________________________________________
Current Address Since: ________________________________________________________
(Mo/Yr) (Street) (City) (Zip Code)
Previous Address from: ________________________________________________________
(Mo/Yr) (Street) (City) (Zip Code)
Previous Address from: ________________________________________________________
(Mo/Yr) (Street) (City) (Zip Code)
SSS Number: _____________________________________ DOB: ______________________
Telephone / Cellphone Number: __________________________________________________
Drivers License Number: _______________________________________________________
The information contained in this application is correct to the best of my knowledge.
I hereby authorize ______________________________________and its designated agents
and representatives to conduct Background Investigation on me as a requirement for my
employment in the above mentioned company. I understand that the scope of the Background
Investigation may include, but not limited to the following areas; family background, current and
previous residences, credit and financial history, employment history, educational background,
character references, civil and criminal history records from any government agencies (LGU,
PNP, PDEA, NBI, MTC and RTC) and other governmental institutions / GOCCs if deemed
necessary.
I further authorize any individual, company, firm, corporation or government agencies/GOCCs to
devulge any and all information, verbal or written, pertaining to me to
_______________________________or its agents and representatives. I further authorize the
complete release of any records or data pertaining to me which the individual, company, firm,
corporation or government agencies/GOCCs may have to include information or data received
from other sources.
_______________________________ and its designated agents and representatives shall
maintain all information received from this authorization in a confidential manner in order to
protect the applicant’s personal information.
______________________________ ___________________ _______________
Name Signature Date Signed
