* First Name Middle * Last Name * Address Apt. # * City *State * Zip *Phone * Date of Birth *Social Security#
In connection with my application for certification (including contract for services) with you, I understand that consumer reports which may contain public record information may be requested from H&O Transport. These reports may include the following type of information: names and dates of previous employers, reason for termination of employment, work experience, accidents, etc. I further understand that such reports may contain public record information concerning my driving record, workers compensation claims, credit, bankruptcy proceedings, criminal records, etc., from federal, state and other agencies which maintain such records; as well as information from H&O concerning previous driving record requests made by others from such state agencies, and state provided driving records.
I AUTHORIZE, WITHOUT RESERVATION, ANY PARTY OR AGENCY CONTACTED BY H&O TO FURNISH THE ABOVE-MENTIONED INFORMATION.
I have the right to make a request to H&O, upon proper identification, to request the nature and substance of all information in its files on me at the time of my request, including the sources of information; and the recipients of any reports on me which H&O has previously furnished within the two year period preceding my request. I hereby consent to your obtaining the above information from H&O, and I agree that such information which H&O has or obtains, and my employment history with you if I am hired, will be supplied by H&O to other companies which subscribe to H&O Services.
I hereby authorize procurement of consumer report(s). If hired (or contracted), this authorization shall remain on file and shall serve as ongoing authorization for you to procure consumer reports at any time during my employment (or contract) period.