Background Check

Date*
Driver's License #
Camp Fire Staff Contact
Last Name*
Middle Name*
First Name*
Maiden Name / Aliases
Street Address*
Apt. #
City*
County*
State & Zip*
Date of Birth*
Gender*
- Male
- Female
Authorization Statement
This authorization and consent for release of personal information acknowledges that Camp Fire Snohomish County and/or its agent, Trak-1 Technology, may now, or at any time I am assigned to, volunteer with or am employed by this Company, conduct investigations whether the records are of a public, private or confidential nature. These investigations might include, but are not limited to, searches of educational institutions attended, state driving records, financial or credit institutions, including records of loans, records of commercial or retail credit agencies, other financial statements, records of previous employment, including work history, efficiency ratings, complaints and grievances filed by or against me, records and recollections of attorney-at-law or of other counsel, whether representing me or any other person (in either a civil or criminal case in which I have been involved), records from the U.S. Veteran’s Administration, criminal history information of file in local, state, or federal agencies, and motor vehicle records, and following an employment offer, worker’s compensation reports from either the Department of Labor, National Personnel Records or the Industrial Commission of National Personnel Records Center, or other custodian of my military service record, to release to Trak-1 Technology, the following information and/or copies of documents from my military service record: DD124, service record, and any disciplinary records.
I understand that these searches will be used to determine work assignments or employment eligibility under the Company’s employment or volunteer policies. Therefore, I authorize and consent for full release of records (either orally or in writing) to the authorized representatives of the Company. In addition, I release and discharge the Company and its agent and associates to the full extent permitted by law from any claims, damages, losses, liabilities, costs expenses or any other charge or complain filed with any agency arising from retrieving and reporting this information. I understand that according to the Federal Fair Credit Reporting Act, I am entitled to know whether employment was denied based upon the information obtained and to receive, upon written request, a disclosure of the background report. I also understand that I may request a copy of the report from: Trak-1 Technology / PO Box 130159 / Houston, TX 77219 at telephone number 1-800-600-8999. After reading this document, I fully understand its contents and authorize the background verification.
Are you applying for employment in California, Minnesota, or Oklahoma?*
- Yes
- No
If so, do you want a copy of any Consumer Report prepared concerning you?
- Yes
- No
I understand that California law required Company to give me a copy of any report requested within seven (7) days of the date the information was obtained and that failure to do so will expose Company to liability )Section 1786.29).
*AS SHOWN ON ORIGINAL APPLICATION **TO BE USED ONLY FOR CRIMINAL HISTORY SEARCHES, AND NOT PART OF THE PERSONNEL FILE.
The following are my responses to questions about my criminal record history (if any) with descriptions to any question with a Yes answer:
1) Have you ever been convicted or plead guilty before a court of any federal, state, or minicipal criminal offense? (Excluding minor traffic violations)*
- Yes
- No
If yes, please provide an explanation below.
2) Have you ever received deferred adjudication or similar disposition for any federal, state or municipal criminal offense? (Excluding minor traffic violations)*
- Yes
- No
If yes, please provide an explanation below.
3) Have you ever received probation or community supervision for any federal, state or municipal criminal offense?*
- Yes
- No
If yes, please provide an explanation below.
4) Have you ever been arrested for molesting or abusing a minor?*
- Yes
- No
If yes, please provide an explanation below.
5) Have you ever been convicted of any criminal offense in a country outside of the jurisdiction of the United States?*
- Yes
- No
If yes, please provide an explanation below.
6) As of the date of this authorization, do you have any pending criminal charges against you?*
- Yes
- No
If yes, please provide an explanation below.
This section is to be used to list all the counties and states of residence since age 18 or High School graduation. You must be specific about dates of residence.
Residence #1
City/Town*
County*
State*
Date From*
Date To*
Additional Residences
Residence #2) City/Town
County
State
Date From
Date To
Residence #3) City/Town
County
State
Date From
Date To
Residence #4) City/Town
County
State
Date From
Date To
Residence #5) City/Town
County
State
Date From
Date To
Residence #6) City/Town
County
State
Date From
Date To
Residence #7) City/Town
County
State
Date From
Date To
Residence #8) City/Town
County
State
Date From
Date To
Residence #9) City/Town
County
State
Date From
Date To
I HEREBY CERTIFY THAT ALL INFORMATION PROVIDED IN THIS AUTHORIZATION IS TRUE, CORRECT AND COMPLETE. I UNDERSTAND THAT IF ANY INFORMATION PROVES TO BE INCORRECT OR INCOMPLETE THAT GROUNDS FOR THE CANCELLING OF ANY AND ALL OFFERS OF EMPLOYMENT WILL EXIST AND MAY BE USED AT THE DISCRETION OF CAMP FIRE SNOHOMISH COUNTY.
By checking this box, I am agreeing to the above statement.*
- YES

Background Check

Authorization Statement

*AS SHOWN ON ORIGINAL APPLICATION **TO BE USED ONLY FOR CRIMINAL HISTORY SEARCHES, AND NOT PART OF THE PERSONNEL FILE.

This section is to be used to list all the counties and states of residence since age 18 or High School graduation. You must be specific about dates of residence.

Residence #1

Additional Residences