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Management Information Services |
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RELEASE OF LIABILITY |
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I,______________________________________________, Date of Birth ____/_____/_____ , (month and day only if used for employment) Social Security Number __________________________, do hereby authorize Management Information Services, of Cleveland, Ohio, to conduct a background investigation into the following areas of my personal and employment history: current and previous employment, education, credit, driving records, criminal and civil records, professional licensing, and general character including honesty. |
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| My drivers license number is _____________________________ and was issued by the state of _______. | ||
| Sex: ( )Male ( )Female
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| ADDRESS INFORMATION: |
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| Current address:
_____________________________________________________________________________________
Length at current address: ____________ (If less than 7 years please provide previous addresses) Previous address (1): __________________________________________________________________________________ Previous address(2): __________________________________________________________________________________ Length at previous address(1): ____________ , Length at previous address(2): _______________. |
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| AUTHORIZATION & RELEASE: | ||
| I hereby authorize any person, agent,
corporation, company, agency, or institution, to release any information, documents, or
assessments they possess regarding me or my performance as an employee, student,
associate, or acquaintance. I release, and permanently hold harmless, Management Information Services., their agents and assigns, and the REQUESTER and their agents and assigns, from any and all demands and or liabilities that may originate from these investigations, or any demand or liability which may result from any physical examination, drug testing procedure, x-rays, or other medical screening procedures conducted by them or their agents, and any person, corporation, company, institution, or their agents who may act upon the authority of this release. I hereby authorize that a photocopy or electronic facsimile of this document shall serve as an original. If a notarized copy of this document is required for any background check, the notarized copy will be provided. Applicant Signature: ____________________________________________________________ Date: ___________________ |
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| REQUESTER INFORMATION: | ||
| As THE REQUESTER, Witness:
Signature: ___________________________________ Date: _________________________ Printed Name: ______________________________________________ Address:__________________________________________ City:________________________State:____ZipCode____________ Phone: _______________________________ Fax:______________________________ |
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Please fax to Management Information Services at (216) 241-3227 |
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