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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Previous Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest 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.
