CONSENT DOCUMENT

(Rev. 6/07)

Prospective Employer: Bexar County Medical Society (BEXAR)

Service Code: National criminal background check (Includes 47 States)

NOTICE TO JOB APPLICANTS

Your prospective employer contracts with employee screening services, Texas licensed, private investigations agency, to verify certain information in your application for employment, conditional job offer or provided by you during the interview process. The information requested below is necessary to complete this task.  This information is NOT a part of the job application for employment and will be used for the sole purpose of verification of information, and or statements made by you. Please complete all information requested.

APPLICANT’S LEGAL NAME:___________________________________________________

 Last  Name                  First                 M.I.

CURRENT HOME ADDRESS:       

       From:                  To:                

HOME PHONE:  (     )   MOBILE PHONE:  (     )  

E-MAIL ADDRESS:                                                                                   

DATE OF BIRTH:                           SOCIAL SECURITY#                         

   Month/Day/Year

DRIVER’S LICENSE #:    STATE:   

RESIDENTIAL HISTORY: LIST ALL RESIDENTIAL ADDRESSES IN THE LAST 7 YEARS

       From:                  To:                

Address                            City                               State                            ZIP

       From:                  To:                

Address                            City                               State                            ZIP

       From:                  To:                

Address                            City                               State                            ZIP

       From:                  To:                

Address                            City                               State                            ZIP

It is possible that your employment may be determined in whole or in part by your prospective employer using data from a report supplied by an Employee Screening Service. Pursuant to Section 609 of the Fair Credit Reporting Act, you may be entitled to a copy of this report.

APPLICANT CONSENT: I understand and agree that an employee screening service will verify all or part of the information I have given my prospective employer.  I understand that this verification may include any inquiry into my credit history, motor vehicle driving record, criminal and civil records, prior employment (including contacting prior employers), education (degree, GPA and attendance) as well as other public record information. I authorize the release of such information as may be necessary to verify the information I have provided. I release and hold harmless from all liability any individual or entity requesting or supplying information with respect to my application for employment.

APPLICANT SIGNATURE:                                                           DATE: