Team Member Background Check FormI am serving as a team member on:(Required) Girl's BVN #28 Boy's BVN #28 Both Girl's BVN #28 and Boy's BVN #28Background Check Concent Form: I certify and declare under penalty of perjury under relevant state and federal law that the information contained in my application is complete, true, and accurate. I acknowledge that falsification or omission of information may result in immediate dismissal or retraction of any offer of residence. In consideration of Birmingham Vida Nueva (BVN)'s review of my application, I herby voluntarily consent to and authorize BVN, or its authorized agents bearing this release or copy thereof, to obtain a consumer report. I agree that this consumer report may include any of the following. * Employment Verification, Education Verification, Credentials Verification, Personal Identity Verification, Past Employment Verification, Reference Checks, Criminal Records, Civil Cases, Motor Vehicle Records, Credit Report. I authorize all persons and organizations that may have information relevant to this research to disclose such information to BVN or its authorized agents. I hereby release BVN, its authorized agents, and all persons and organizations providing information from all claims and liabilities of any nature in connection with this research. I hereby further authorize that a photocopy of this authorization may be considered as valid as the original. I understand that I have specific prescribed rights as a consumer under the federal Fair Credit Reporting Act (FCRA), and may have additional rights under relevant state law. I hereby certify that I have been informed of my rights.Signature of Applicant(Required)Today's Date(Required) MM slash DD slash YYYY First & Last Name(Required)Maiden Name(s)Date of Birth(Required)Social Security Number(Required)Driver's License Number(Required)State of Issue(Required)Current Address(Required) Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Previous Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code EMPLOYER TO CHECK SERVICES TO BE COMPLETED: _ALABAMA STATEWIDE CRIMINAL _PEER CREDIT REPORT; _STATEWIDE CRIMINAL _PREVIOUS EMPLOYMENT VERIFICATION; _COUNTY CRIMINAL _REFERENCE VERIFICATION _SOCIAL SECURITY TRACE _WORKER'S COMP; _MOTOR VEHICLE REPORT _EDUCATION VERIFICATION; _SEXUAL OFFENDER REGISTRY _OIG EXCLUSIONSSTATE(S)________________ COUNTY_________________ ***NOTE:FOR EDUCATION AND EMPLOYMENT VERIFICATION PLEASE SUPPLY ADDITIONAL INFORMATION (RESUME OR APPLICATION) **INFORMATION IS BEING VERIFIED BY QUALITY COUNTS, INC. ANY INFORMATION OR QUESTIONS SHOULD BE DIRECTED TO THE FOLLOWING ADDRESS: QUALITY COUNTS, INC. PHONE:205-561-2340 FAX:205-561-2344 OR 877-349-1990CommentsThis field is for validation purposes and should be left unchanged.
