Team Member Background Check Form - Birmingham Vida Nueva

I am serving as a team member on:*

Girl's BVN #26
Boy's BVN #26
Both Girl's BVN #26 and Boy's BVN #26

Background 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*

Today's Date*

Social Security Number*

Full Name*

Maiden Name(s)

Date of Birth*

Driver's License Number*

State of Issue*

Current Address*

Street Address Address Line 2 City State ZIP Code

Previous Address

Street Address Address Line 2 City 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 EXCLUSIONS

STATE(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 877-349-1990

Name

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